Pre- and Post-Transplant Screening Guidelines by Organ System
Universal Pre-Transplant Screening (All Solid Organ Transplants)
All transplant candidates must undergo comprehensive infectious disease screening for both donor and recipient, as this directly impacts morbidity and mortality through prevention of donor-derived infections and reactivation of latent recipient infections. 1
Core Infectious Disease Testing (Donor and Recipient)
- HIV 1/2 antibody testing via enzyme-linked immunoassay is mandatory for all donors and recipients; high-risk donors require additional nucleic acid testing (NAT) to reduce the window period to 5-10 days 1, 2
- Hepatitis B surface antigen (HBsAg) and total core antibody (HBcAb) must be tested in all donors and recipients; HBsAg-positive donors are contraindicated except for HBsAg-positive recipients or those with protective immunity 1, 2, 3
- Hepatitis C antibody (HCV) is required for all donors and recipients; HCV-positive donors are contraindicated except when donating to HCV-positive recipients 1, 2, 3
- Cytomegalovirus (CMV) IgG antibody is essential to define prophylactic strategy post-transplant based on donor-recipient serology matching 1, 2
- Epstein-Barr virus (EBV) IgG antibody is required to monitor EBV-negative recipients, especially children at higher risk for post-transplant lymphoproliferative disorder 1, 2
- Rapid plasma reagin (RPR) or other serological test for syphilis is recommended; syphilis-positive donors are acceptable with recipient treatment 1, 2
- Blood cultures should be collected from donors at time of organ procurement, especially if hospitalized >48-72 hours 1
Clinical Evaluation Requirements
- Medical and social history focusing on risk factors for transmissible diseases including sexual history, intravenous drug use, incarceration, tattoos, and travel to endemic areas 1, 2
- Physical examination to identify signs of acute or chronic infection 1, 2
- Chest radiograph to screen for pulmonary pathology including tuberculosis 1, 2
- Tuberculin skin test (TST) for recipients; donors with active TB are contraindicated (RL1), but latent TB without active infection is acceptable (RL3) with recipient prophylaxis 1
Critical Timing for Testing
- All infectious disease testing must be current within 28 days of donation to ensure accuracy 2, 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, 4
- Active infections require minimum 2 weeks after recovery before transplantation, though this can be shortened in life-threatening situations 1
Organ-Specific Screening Guidelines
Lung Transplantation
Pre-Transplant Donor Screening
- Bronchoscopy with bronchoalveolar lavage is required for lung donors to identify bacterial, fungal, and mycobacterial colonization 1
- Gram stain and culture of respiratory secretions must be performed; utilization of lungs with gram-negative bacteria or fungal infections is controversial (RL2-3) but acceptable with aggressive antibiotic therapy 1
- Influenza testing during annual epidemic periods; donors with confirmed/suspected influenza should be ruled out for lung transplantation 1
Pre-Transplant Recipient Screening
- Bronchoscopy with bronchoalveolar lavage at time of procedure to identify airway colonization 1
- Screening for Pseudomonas, Burkholderia, nontuberculous mycobacteria, Aspergillus, and Scedosporium as these tend to recur post-transplant 5
- B. cenocepacia and M. abscessus are relative contraindications due to poor outcomes 5
Post-Transplant Monitoring
- Monitor for tracheobronchitis or bronchial anastomotic infection (unique to lung transplant), defined as fungal pathogen isolation with histopathologic evidence of tissue invasion 1
- Surveillance for invasive fungal infections (15-35% incidence in lung transplants), primarily Candida and Aspergillus 1
Liver Transplantation
Pre-Transplant Screening (HCV-Specific)
- HCV screening via EIA ± qualitative PCR for all liver transplant candidates 1
- Pre-transplant quantitative HCV viral load measured once for HCV-positive patients 1
- Genotyping recommended in all transplant trials enrolling HCV-infected patients 1
- Pre-transplant liver biopsy to establish baseline in HCV-positive patients 1
Post-Transplant Monitoring
- HCV RNA quantitative viral loads at baseline, 3,6,9, and 12 months post-transplant 1
- Routine surveillance biopsies twice within first year: at 4-6 months and 10-12 months post-transplant, plus as clinically indicated for elevated liver enzymes 1
- Histologic grading using standard systems (Batts and Ludwig, METAVIR, or Knodell HAI) for necroinflammatory activity and fibrosis 1
- Invasive fungal infection surveillance (7-42% incidence in liver transplants) 1
Kidney Transplantation
Pre-Transplant Screening
- Standard infectious disease panel as outlined in universal screening above 2
- Urinalysis to detect asymptomatic urinary tract infections 4
- For living donors with travel to endemic areas (e.g., Guatemala, Belize): parasitic infection testing via stool examination for ova and parasites, consideration for malaria testing if visiting rural areas, and arbovirus testing if symptomatic 4
Post-Transplant Monitoring
- Invasive fungal infection surveillance (2-14% incidence in renal transplants, lowest among solid organ transplants) 1
- CMV prophylaxis based on donor-recipient serology matching 2, 3
Heart Transplantation
Pre-Transplant Screening
- Toxoplasma IgG antibody for both heart donors and recipients; prophylaxis required for seronegative recipients receiving seropositive donor hearts due to transmission risk up to 75% without prophylaxis 1
- Standard infectious disease panel as outlined in universal screening 1
Post-Transplant Monitoring
- Toxoplasmosis surveillance in D+/R- mismatched recipients 1
- Invasive fungal infection surveillance (15-35% incidence in heart-lung transplants) 1
Bone Marrow/Hematopoietic Stem Cell Transplantation
Pre-Transplant Screening
- Standard viral serology panel (HIV, HBV, HCV, CMV, EBV) for donors and recipients 1
- Tuberculin skin test for recipients 1
Post-Transplant Monitoring
- Invasive fungal infection surveillance using EORTC/MSG criteria; only proven and probable infections should be reported 1
- CMV monitoring based on donor-recipient serology status 1
Post-Transplant CMV Prophylaxis Strategy
CMV prophylaxis timing and duration must be tailored to donor-recipient serology matching, with high-risk (D+/R-) patients requiring extended prophylaxis.
High-Risk Kidney Transplant Patients (D+/R-)
- Valganciclovir 900 mg once daily for 200 days post-transplant is superior to 100-day regimen, reducing CMV disease from 36.8% to 16.8% at 12 months 6
- Initiate within 10 days of transplantation 6
Other Solid Organ Transplants (Heart, Liver, Kidney, Kidney-Pancreas)
- Valganciclovir 900 mg once daily for 100 days post-transplant starting within 10 days of transplantation for D+/R- patients 6
Pediatric Patients (4 months to 16 years)
- Dose calculated based on body surface area and modified creatinine clearance 6
- Continue for maximum 100 days post-transplant 6
Risk Stratification Framework for Donor Utilization
The Alliance-O classification system guides decision-making on donor organ utilization based on infection risk levels. 1
Risk Level 1 (RL1) - Unacceptable Risk
- Absolute contraindications: Active TB, meningoencephalitis from Cryptococcus neoformans or M. tuberculosis, rabies, lymphocytic choriomeningitis virus, arenaviruses, prion diseases 1
Risk Level 2-3 (RL2-3) - Increased but Acceptable/Calculated Risk
- Bacteremia with appropriate antimicrobial therapy ≥48 hours and clinical control 1
- Fungemia with targeted therapy 1
- Lung colonization with gram-negative bacteria or fungi with aggressive antibiotic therapy 1
- HBsAg-positive or HCV-positive donors for matched recipients 3
Risk Level 5 (RL5) - Standard Risk
- No transmissible disease identified during evaluation 1
Common Pitfalls and Critical Considerations
Window Period Testing
- False-negative results occur during window periods: HIV (5-10 days with NAT), HCV (3-5 days with NAT), HBV (20-22 days with NAT) 3, 4
- NAT reduces but does not eliminate window period risk 3, 4
Multidrug-Resistant Organisms
- Carbapenemase-producing Gram-negative bacteria, pan-resistant P. aeruginosa, and vancomycin-resistant Enterococcus require careful risk-benefit analysis in both donors and recipients 1
- Knowledge of recipient colonization guides antibiotic prophylaxis during procedure 1
Geographic and Travel-Related Infections
- Travel history is paramount for screening geographically restricted infections 1, 4
- Endemic fungal infections, flaviviruses, and parasitic diseases require additional testing based on exposure 4, 7
Timing of Active Infections
- Cholangitis in liver transplant, ventricular assist device infections in heart transplant, and P. aeruginosa colonization in cystic fibrosis lung transplant will only resolve with the procedure itself—do not delay transplantation 1