Elmi Muller

The risk of tuberculosis in transplant candidates and recipients: a TBNET consensus statement

Tuberculosis (TB) is a possible complication of solid organ and hematopoietic stem cell transplantation. The identification of candidates for preventive chemotherapy is an effective intervention to protect transplant recipients with latent infection with Mycobacterium tuberculosis from progressing to active disease. The best available proxy for diagnosing latent infection with M. tuberculosis is the identification of an adaptive immune response by the tuberculin skin test or an interferon-&ggr; based ex vivo assay. Risk assessment in transplant recipients for the development of TB depends on, among other factors, the locally expected underlying prevalence of infection with M. tuberculosis in the target population. In areas of high prevalence, preventive chemotherapy for all transplant recipients may be justified without immunodiagnostic testing while in areas of medium and low prevalence, preventive chemotherapy should only be offered to candidates with positive M. tuberculosis-specific immune responses. The diagnosis of TB in transplant recipients can be challenging. Treatment of TB is often difficult due to substantial interactions between anti-TB drugs and immunosuppressive medications. This management guideline summarises current knowledge on the prevention, diagnosis and treatment of TB related to solid organ and hematopoietic stem cell transplantation and provides an expert consensus on questions where scientific evidence is still lacking.

Renal Transplantation between HIV-Positive Donors and Recipients

Investigators in South Africa undertook four renal transplantations involving HIV-positive donors and HIV-positive recipients with end-stage renal disease. At 12 months after transplantation, all recipients had good renal function and had not needed dialysis since the procedure.

The critical pathway for deceased donation: reportable uniformity in the approach to deceased donation

The critical pathway of deceased donation provides a systematic approach to the organ donation process, considering both donation after cardiac death than donation after brain death. The pathway provides a tool for assessing the potential of deceased donation and for the prospective identification and referral of possible deceased donors.

HIV-Positive–to–HIV-Positive Kidney Transplantation — Results at 3 to 5 Years

BACKGROUND The outcome of kidney transplantation in human immunodeficiency virus (HIV)-positive patients who receive organs from HIV-negative donors has been reported to be similar to the outcome in HIV-negative recipients. We report the outcomes at 3 to 5 years in HIV-positive patients who received kidneys from HIV-positive deceased donors. METHODS We conducted a prospective, nonrandomized study of kidney transplantation in HIV-infected patients who had a CD4 T-cell count of 200 per cubic millimeter or higher and an undetectable plasma HIV RNA level. All the patients were receiving antiretroviral therapy (ART). The patients received kidneys from deceased donors who tested positive for HIV with the use of fourth-generation enzyme-linked immunosorbent assay at the time of referral. All the donors either had received no ART previously or had received only first-line ART. RESULTS From September 2008 through February 2014, a total of 27 HIV-positive patients underwent kidney transplantation. Survivors were followed for a median of 2.4 years. The rate of survival among the patients was 84% at 1 year, 84% at 3 years, and 74% at 5 years. The corresponding rates of graft survival were 93%, 84%, and 84%. (If a patient died with a functioning graft, the calculation was performed as if the graft had survived.) Rejection rates were 8% at 1 year and 22% at 3 years. HIV infection remained well controlled, with undetectable virus in blood after the transplantation. CONCLUSIONS Kidney transplantation from an HIV-positive donor appears to be an additional treatment option for HIV-infected patients requiring renal-replacement therapy. (Funded by Sanofi South Africa and the Roche Organ Transplantation Research Foundation.).

Living and deceased organ donation should be financially neutral acts

The supply of organs—particularly kidneys—donated by living and deceased donors falls short of the number of patients added annually to transplant waiting lists in the United States. To remedy this problem, a number of prominent physicians, ethicists, economists and others have mounted a campaign to suspend the prohibitions in the National Organ Transplant Act of 1984 (NOTA) on the buying and selling of organs. The argument that providing financial benefits would incentivize enough people to part with a kidney (or a portion of a liver) to clear the waiting lists is flawed. This commentary marshals arguments against the claim that the shortage of donor organs would best be overcome by providing financial incentives for donation. We can increase the number of organs available for transplantation by removing all financial disincentives that deter unpaid living or deceased kidney donation. These disincentives include a range of burdens, such as the costs of travel and lodging for medical evaluation and surgery, lost wages, and the expense of dependent care during the period of organ removal and recuperation. Organ donation should remain an act that is financially neutral for donors, neither imposing financial burdens nor enriching them monetarily.

Medical students' knowledge about organ transplantation: a South African perspective.

BACKGROUND Educating physicians about transplantation during undergraduate training can improve organ procurement rates. The aim of this study was to evaluate and analyze the knowledge of medical students regarding transplantation. METHODS A previously validated self-administered anonymous questionnaire was distributed to all medical students. RESULTS Of the 346 participants, 217 (63%) were preclinical students. Their mean age was 21 years (range, 18-33) and 62% were women. Twenty-nine (8%) students were registered as organ donors. One third of all study participants received formal transplantation teaching; a greater proportion of clinical students received teaching compared with the preclinical group (52% vs 22%, P < .05). Knowledge was frequently reported for kidney (88%), liver (81%), bone marrow (78%), and heart (76%) transplantation. Small Intestine (13%), pancreas (9%), and pancreatic islets (4%) were the least recognized organs/tissues. Ninety-six percent and 62% of respondents were aware of kidney and liver living-donor transplants, respectively; the 27% of students with an interest in a surgical career had better knowledge of living-donor transplantation (P < .05). Only 22 (6%) students knew which solid organ transplants were performed in South Africa. CONCLUSION Medical students have limited knowledge about organ transplantation; there is a need for educational intervention early in the medical curriculum.

Attitudes and beliefs of South African medical students toward organ transplantation.

Sobnach S, Borkum M, Millar AJW, Hoffman R, Muller E, McCurdie F, Kahn D. Attitudes and beliefs of South African medical students toward organ transplantation. 
Clin Transplant 2011 DOI: 10.1111/j.1399‐0012.2011.01449.x. 
© 2011 John Wiley & Sons A/S.

Prevention of Transnational Transplant-Related Crimes-What More Can be Done?

Background Many nations are able to prosecute transplant-related crimes committed in their territory, but transplant recipients, organ sellers and brokers, and transplant professionals may escape prosecution by engaging in these practices in foreign locations where they judge the risk of criminal investigation and prosecution to be remote. Methods The Declaration of Istanbul Custodian Group convened an international working group to evaluate the possible role of extraterritorial jurisdiction in strengthening the enforcement of existing laws governing transplant-related crimes across national boundaries. Potential practical and ethical concerns about the use of extraterritorial jurisdiction were examined, and possible responses were explored. Results Extraterritorial jurisdiction is a legitimate tool to combat transplant-related crimes. Further, development of a global registry of transnational transplant activities in conjunction with a standardized international referral system for legitimate travel for transplantation is proposed as a mechanism to support enforcement of national and international legal tools. Conclusions States are encouraged to include provisions on extraterritorial jurisdiction in their laws on transplant-related crimes and to collaborate with professionals and international authorities in the development of a global registry of transnational transplant activities. These actions would assist in the identification and evaluation of illicit activities and provide information that would help in developing strategies to deter and prevent them.

HIV-positive-to-HIV-positive kidney transplantation.

To the Editor: Muller et al. (Feb. 12 issue)1 report that among 27 patients with human immunodeficiency virus (HIV) infection who received kidneys from HIV-positive deceased donors, recurrent HIV-associated nephropathy developed in the transplanted kidney in 3 patients, even though viremia was undetectable. This observation is consistent with our recent report showing that the allografted kidney is a reservoir for HIV type 1 (HIV-1).2 The glomerular lesions in the 3 patients might be the tip of the iceberg, since we observed that up to 68% of transplant recipients with HIV-1 infection have virus in kidney cells after transplantation, even with normal results on histologic analysis. In addition, we found that the presence of HIV-1 in a kidney correlates with the presence of HIV-1 in the patient’s urine. Indeed, the identification of virus in the urine is associated with the presence of HIV-1 in the kidney. The situation is highly relevant for HIV-1–positive donors, because lesions might be related to the virus in the recipient, the donor, or both. We suggest that looking at HIV-1 that is shed into the urine or detected on biopsy might help to monitor kidneygraft infection and also allow the determination of which virus (from donor or recipient) is involved by means of phylogenetic analysis.

Regional perspective: developing organ transplantation in sub-saharan Africa.

THE NEED FORORGAN TRANSPLANTATION IN SUB-SAHARAN AFRICA The availability of renal replacement therapy is unequivocally lower in Africa than in any other region of the world; however, the true scale of the unmet need for treatment of end-stage kidney disease (ESKD) in the African region is unknown. Ideally, population-based studies, death registration data, and registries of dialysis and organ transplantation would enable quantitative estimation of the underlying burden of ESKD and its risk factors in the African population. Such data are largely unavailable; yet it is likely that rates of ESKD exceed those of developed countries because of a high prevalence of undetected hypertension, diabetes, and human immunodeficiency virus, combined with undiminished rates of infection-related nephropathies. In addition, economic realities affecting access to health care and the limited capacity for the medical management of these primary causes of ESKD potentially result in a more rapid progression to organ failure than experienced in highincome countries (1). Given demographic trends in the subSaharan African region, an increasing burden of chronic disease, and economic developments affecting access to health care, health ministries can anticipate an increased demand for organ transplantation in the coming years.