What are the risks to both the recipient and donor if a potential kidney donor has undiagnosed malaria?

Risks of Undiagnosed Malaria in a Potential Kidney Donor

Organs from a potential kidney donor with undiagnosed malaria should be rejected if the donor's death is secondary to malaria. Otherwise, both the donor and recipient should be treated for malaria to prevent transmission and complications. 1

Risks to the Recipient

• Donor-derived malaria transmission is a serious risk for kidney transplant recipients, potentially causing severe illness due to immunosuppression 2
• Recipients may develop various clinical manifestations including:
  • Fever, myalgia, and arthralgia 2
  • Acute kidney failure 2
  • Neurological complications including seizures 2
  • Thrombocytopenia 2
• Malaria transmission can occur even when standard donor screening protocols are followed, as demonstrated by cases where donors tested negative on thick blood smear examination 3
• The immunosuppressed state of transplant recipients increases the risk of severe or fatal outcomes from donor-derived malaria infection 1

Risks to the Donor

• For living donors with undiagnosed malaria:
  • Potential for clinical deterioration during the perioperative period due to surgical stress and immune changes 4
  • Risk of reactivation or worsening of subclinical malaria infection following donation 4
  • Possible complications during recovery from nephrectomy if malaria becomes symptomatic 4
• Living donors from endemic areas may harbor parasites for extended periods (up to 15 years for P. malariae) without symptoms 5

Screening and Prevention Recommendations

• All potential kidney donors who have resided in or traveled to endemic areas within the preceding 3 years should be screened for malaria 1
• Nucleic acid testing (NAT) is more sensitive than conventional microscopy for detecting low-level parasitemia 1
• Conventional screening methods include:
  • Thick and thin blood films with Giemsa stain 1
  • Immunochromatography (IC) for diagnosis 1
• Testing should be performed at least 4 weeks after return from travel to allow adequate detection of potential infections 6

Management Recommendations

• If a potential living donor is found to have malaria, treatment should be completed before donation is considered 1
• For deceased donors with undiagnosed malaria:
  • Organs should be rejected if the donor's death is secondary to malaria 1
  • If malaria is discovered after transplantation, prompt treatment of the recipient is essential 2
• Recipients of organs from donors with risk factors for malaria should receive prophylactic antimalarial treatment 4

Special Considerations

• Standard screening questionnaires may be insufficient to identify all donors at risk, particularly those who immigrated from endemic areas many years ago 5
• Malaria can persist in semi-immune individuals for extended periods without symptoms:
  • P. falciparum: typically months 3
  • P. vivax and P. ovale: up to 3 years 2
  • P. malariae: up to 15 years or more 5
• Transmission has been documented even when donors have been away from endemic areas for extended periods (>15 years in some cases) 5

Common Pitfalls to Avoid

• Relying solely on thick blood smear examination, which can miss low-level parasitemia 3
• Assuming that time away from endemic areas eliminates risk, as some Plasmodium species can persist for many years 5
• Overlooking the need for malaria screening in donors who immigrated from endemic areas years ago 5
• Failing to consider malaria when evaluating post-transplant fever in recipients of organs from donors with risk factors 2

By implementing comprehensive screening protocols and appropriate prophylactic measures, the risk of donor-derived malaria transmission can be significantly reduced, protecting both donors and recipients from potentially serious complications.