What infectious disease tests are required for a kidney donor?

Infectious Disease Testing for International Living Kidney Donors

All living kidney donors coming to the US must undergo comprehensive infectious disease screening that includes HIV, hepatitis B and C, CMV, EBV, syphilis, and blood cultures, with all testing completed within 28 days of the planned donation surgery. 1

Core Required Testing

Viral Infections (Required for All Donors)

• HIV 1/2 antibody testing using enzyme-linked immunoassay (EIA) is mandatory, with high-risk donors requiring additional nucleic acid testing (NAT) to reduce the window period from 5-10 days 1, 2

• Hepatitis B surface antigen (HBsAg) and total core antibody (HBcAb) must be tested; HBsAg-positive donors are generally contraindicated except for HBsAg-positive recipients or those with protective immunity 1

• Hepatitis C antibody (HCV) is required; HCV-positive donors are contraindicated except when donating to HCV-positive recipients 1

• Cytomegalovirus (CMV) IgG antibody is essential to define prophylactic strategy post-transplant based on recipient serology 1

• Epstein-Barr virus (EBV) IgG antibody is necessary to monitor EBV-negative recipients, particularly children who are at higher risk for post-transplant lymphoproliferative disorder 1

Bacterial Infections

• Rapid plasma reagin (RPR) or other serological test for syphilis is required; positive results do not contraindicate donation but require recipient treatment 1

• Blood cultures should be obtained from the donor, particularly if there has been recent hospitalization (>48-72 hours); multidrug-resistant bacteria require individual evaluation 1, 2

Parasitic Infections

• Toxoplasma IgG antibody testing is recommended, especially for heart transplant donors in areas of high endemicity 1

Additional Clinical Evaluation

• Complete medical and social history focusing on risk factors for transmissible diseases, including sexual history, intravenous drug use, incarceration, and tattoos 1

• Physical examination to identify signs of acute or chronic infection 1

• Chest radiograph to screen for pulmonary pathology including tuberculosis 1

• Urinalysis to detect asymptomatic urinary tract infections 2, 3

Critical Timing Considerations

The window period is the most dangerous pitfall in donor screening. Testing must account for the time between potential infection and detectability:

• All infectious disease testing must be current within 28 days of donation to ensure accuracy 2, 3, 4

• For donors with recent travel or high-risk exposures, wait at least 2-4 weeks after return before testing to allow adequate time for seroconversion 2, 3

• NAT testing reduces but does not eliminate window periods: HIV (5-10 days), HCV (3-5 days), HBV (20-22 days) 2, 5

• Some centers perform repeat testing within 7-14 days of the actual donation procedure to catch infections acquired during the evaluation period 4

Geographic-Specific Considerations

While the evidence does not specify the donor's country of origin, international donors may require additional screening based on endemic diseases in their region of residence:

• Parasitic infection screening (stool examination for ova and parasites) should be considered for donors from endemic areas 2

• Malaria testing may be warranted depending on the donor's country of origin 2, 3

• Endemic fungal infections and mycobacterial screening should be evaluated based on geographic risk 2

• Strongyloides and Chagas disease testing is performed by some organ procurement organizations, particularly for donors from endemic regions 6

Absolute Contraindications vs. Acceptable Risk

The guidelines use a risk-level classification system that determines donor eligibility:

• HIV-positive status is an absolute contraindication except when donating to HIV-positive recipients under specific protocols 1

• HBsAg-positive and HCV-positive donors are contraindicated except for matched recipients with the same infection or protective immunity 1

• CMV-positive and EBV-positive donors are not contraindicated but require tailored prophylaxis and monitoring strategies for seronegative recipients 1

• Syphilis-positive donors are acceptable with appropriate recipient treatment 1

Common Pitfalls to Avoid

• Testing too early after potential exposure leads to false-negative results during the window period; this is the single most dangerous error in donor screening 2, 3

• Relying solely on antibody testing without NAT for high-risk donors significantly increases transmission risk, particularly for HCV where undetected infection rates can be as high as 1 in 1,000 for high-risk donors 5

• Failing to obtain detailed travel and exposure history may miss geographically restricted infections that require additional testing 2, 6

• Not consulting infectious disease specialists when evaluating donors with complex exposure histories or positive screening results can lead to inappropriate acceptance or rejection of donors 7, 6

• Overlooking the need for repeat testing close to the donation date in donors with ongoing risk factors or recent exposures 4