Risks for Potential Kidney Donors Traveling to Dengue-Endemic Areas
Potential kidney donors traveling to dengue-endemic areas face significant risks including donor-derived dengue transmission to recipients, which can result in severe dengue, graft dysfunction, and death in immunosuppressed transplant recipients. 1
Primary Risk: Donor-Derived Dengue Transmission
The most critical concern is transmission of dengue virus from an infected donor to the transplant recipient, which has been documented in multiple cases with fatal outcomes. 1
- Donor-derived dengue transmission has been confirmed in kidney transplantation, with documented cases showing that recipients can develop severe dengue post-transplant, including respiratory failure, coagulopathy, and death 1
- In one case series, two recipients received kidneys from the same donor with dengue history—one developed severe dengue and recovered, while the other died from severe dengue with respiratory failure and coagulopathy 1
- No standardized international guidelines currently exist for dengue screening or organ acceptance criteria for donors who have traveled to or lived in endemic areas 1
Clinical Outcomes in Transplant Recipients
The severity of dengue in kidney transplant recipients is substantially higher than in immunocompetent individuals:
- Mortality rates are concerning: in one series of 8 renal transplant recipients with dengue, 3 (37.5%) developed dengue hemorrhagic shock syndrome and died 2
- Severe dengue occurs in 15-15.4% of kidney transplant recipients with dengue infection 3, 4
- Acute graft dysfunction occurs in 59-76.9% of transplant recipients with dengue, with median eGFR reduction of 13.7 mL/min/1.73 m² 3, 4
- Approximately 10-15% of transplant recipients with dengue require dialysis 4
Timing and Detection Challenges
The asymptomatic or presymptomatic period poses the greatest risk to organ donation, as donors may be viremic before symptom onset. 5
- Dengue has an incubation period of 4-8 days after mosquito exposure 5, 6
- PCR testing is most effective only in the first few days of infection during viremia 7
- NS1 antigen detection is useful from day 1 to day 10 after symptom onset 7
- A donor who travels to a dengue-endemic area and donates shortly after return may be in the presymptomatic viremic phase, making detection extremely difficult 5
Risk Stratification for Donor Evaluation
When evaluating a potential donor with dengue exposure:
- Donors with confirmed recent dengue infection should be deferred, though specific timeframes are not established in guidelines 1
- Donors from regions highly endemic for dengue with appropriate epidemiologic history warrant heightened clinical suspicion 5
- Testing should include dengue NAAT on serum if within 7 days of potential exposure, or IgM antibody testing if beyond 7 days 5
Recipient Complications Beyond Transmission
Even if transmission occurs, the clinical presentation in immunosuppressed recipients is severe:
- Dengue with warning signs occurs in 53.8-59% of kidney transplant recipients 3, 4
- CMV coinfection occurs in 19% of transplant recipients with dengue and is associated with worse clinical presentation and recovery 4
- Hemophagocytic lymphohistiocytosis has been reported as a complication in transplant recipients with dengue 3
Critical Pitfalls to Avoid
- Do not proceed with organ procurement from donors with recent travel to dengue-endemic areas without appropriate testing and risk assessment 1
- Do not assume that absence of symptoms in a donor rules out dengue infection, as the presymptomatic viremic period poses the highest transmission risk 5
- Do not underestimate the severity of dengue in immunosuppressed recipients—it carries substantially higher morbidity and mortality than in immunocompetent individuals 2, 4
Practical Recommendation
Given the documented fatal outcomes, lack of standardized screening guidelines, and high rates of severe disease in recipients, potential kidney donors should avoid travel to dengue-endemic areas in the weeks preceding planned donation. 1 If travel has occurred, a minimum waiting period with appropriate serologic and molecular testing should be implemented, though specific timeframes require institutional protocol development given the absence of international guidelines 1.