Screening and Treatment of Chagas Disease in Organ Transplant Recipients in the United States: Recommendations from the Chagas in Transplant Working Group

Abstract

Donor-derived transmission of Trypanosoma cruzi, the etiologic agent of Chagas disease, has emerged as an issue in the United States over the past 10 years. Acute T. cruzi infection causes substantial morbidity and mortality in the posttransplant setting if not recognized and treated early. We assembled a working group of transplant infectious disease specialists, laboratory medicine specialists, organ procurement organization representatives and epidemiologists with expertise in Chagas disease. Based on review of published and unpublished data, the working group prepared evidence-based recommendations for donor screening, and follow-up testing and treatment of recipients of organs from infected donors. We advise targeted T. cruzi screening of potential donors born in Mexico, Central America and South America. Programs can consider transplantation of kidneys and livers from T. cruzi -infected donors with informed consent from recipients. However, we recommend against heart transplantation from infected donors. For other organs, we recommend caution based on the anticipated degree of immunosuppression. Our recommendations stress the need for systematic monitoring of recipients by polymerase chain reaction, and microscopy of buffy coat and advance planning for immediate antitrypanosomal treatment if recipient infection is detected. Data on management and outcomes of all cases should be collected to inform future guidelines and to assist in coordination with public health authorities.

Trypanosoma cruzi and Chagas' Disease in the United States

“…Nineteen instances of transmission by organ transplantation have been documented in the literature (13 kidney, 1 kidney and pancreas, 3 liver, and 2 heart transplants) (16,61,66,79,99,101,157,238,279). The risk from heart transplantation is thought to be higher than that from kidney or liver transplantation (65). One case of transmission through unrelated cord blood transplantation has been reported (104).…”

“…PCR techniques provide the most sensitive tool to diagnose acute-phase and early congenital Chagas' disease and to monitor for acute T. cruzi infection in the recipient of an infected organ or after accidental exposure (32,65,133). PCR assays usually show positive results days to weeks before circulating trypomastigotes are detectable on peripheral blood smears (267).…”

“…More recently, some organ procurement organizations have begun selective or universal screening of donated organs (65). Three transmission events (in two heart recipients in 2006 and 2010 and one liver recipient in 2006) were detected through systematic laboratory monitoring when their respective donors were identified as infected shortly after the transplants occurred.…”

“…When an infected organ donor is detected, recipient monitoring relies primarily on detection of the parasite by microscopy, culture, and/or PCR, because seroconversion may be delayed or never occur in immunocompromised individuals (65,238). Molecular techniques usually show positive results days to weeks before circulating trypomastigotes are visible by microscopy of peripheral blood.…”

“…Transplant-transmitted T. cruzi infection may have a longer incubation period than vector-borne infection; parasitemia is usually detected within 2 to 3 months, but the delay can be as long as 6 months. A frequently recommended monitoring schedule consists of weekly specimens for 2 months, specimens every 2 weeks up to 4 months, and then monthly specimens afterwards (65,238). In the absence of other indications and assuming no evidence of infection has been detected, the monitoring interval can be lengthened after 6 months posttransplantation.…”