[Medscape] — Recipients of hearts from donors who were homeless die sooner and at a higher rate than those getting hearts from donors who weren’t homeless, based on an analysis of the 2005–2009 experience at a major Los Angeles medical center.

The study, small and inconclusive, nonetheless also showed that three of the five early deaths of homeless-donor-heart recipients were associated with major infection, reported Dorothy Lockhart (Cedars-Sinai Medical Center, Los Angeles, CA) at the International Society for Heart & Lung Transplantation 2010 Scientific Sessions. In only one case, however, could the fatal infection be firmly linked to the heart donor.

Lockhart pointed out that the Centers for Disease Control and Prevention (CDC) lists criteria [1] for people with increased risk of infection that could be transmitted if their organs are transplanted and who should therefore be excluded from donating regardless of their HIV-antibody status, “unless the risk to the recipient of not performing the transplant is deemed to be greater than the risk of HIV transmission and disease.” In such exceptions, recipients should give informed consent.

The list includes IV-drug abusers, prostitutes of either sex, and anyone who has had sexual contact with either group or with anyone with “known or suspected HIV-infected blood” or “inmates of correctional systems,” among others, as being high-risk for organ donation. But it doesn’t include people who are homeless, Lockhart noted.

Yet there is evidence that “the homeless may be at increased risk for infection because of their general poor health, with lowered immunity and poor living conditions and hygiene,” she said. Many homeless people “may also be immigrants from other parts of the world with endemic diseases. Organ donation from homeless donors may pose a risk to transmit these infections,” according to Lockhart. “Further study with a larger number of patients is needed to confirm whether homelessness should be added to the CDC high-risk organ-donation category.”

Dr Duane Davis

As the featured discussant for Lockhart’s presentation, Dr Duane Davis (Duke University, Durham, NC) was skeptical of the conclusions, given the study’s retrospective nature, the small number of homeless donors, and other reasons: “I think we need to put this into a broader philosophical [perspective]. Currently we use only 25% of organ donors as heart donors, so looking for an excuse not to transplant probably isn’t the direction we really want to be going in. We want to figure out how we’re going to be able to use all hearts that could be beneficial to other patients.”

To that end, Davis said, and considering the study’s limited evidence that infections in the recipients came from the homeless donors, an analysis that looked for significant predictors of recipient mortality might have been better.

Lockhart responded to heartwire , “I agree that we shouldn’t decrease our donor population and we already have a shortage of donors. But we also have a lot of donors who come from endemic areas where [coccidioidomycosis] is prevalent, Chagas’ [disease] is prevalent, West Nile virus is prevalent. This may be an emerging phenomenon–that we’re starting to see these transmissions more and more. So we really want to make sure we monitor the donors very carefully.”

Currently we use only 25% of organ donors as heart donors, so looking for an excuse not to transplant probably isn’t the direction we really want to be going in.

She and her colleagues had looked at 295 adult heart recipients at her center over five years, of whom 10 received hearts from donors that had been classified as homeless by the organ-procurement organization (OPO). Those 10 were similar to the 285 others with respect to donor and recipient age, sex, ischemic time, and other factors that can influence graft survival.

Survival declined gradually and consistently among the nonhomeless-donor group over three years, but it dropped precipitously during the first six months for those who received homeless-donor hearts. All five deaths in the latter group, three from infection and two from rejection, occurred within nine months of transplantation (p<0.001).

Recipient mortality from infection was significantly increased among those getting homeless-donor hearts, 50% vs 16% for those getting nonhomeless-donor hearts; there were no significant differences in death from rejection, vasculopathy, or multisystem organ failure.

Outcomes of Transplant Recipients With Hearts From Homeless vs Nonhomeless Donors

End point	Homeless donor, n=10	Nonhomeless donor, n=285	p
3-y survival (%)	50	84	0.005
Mean survival after transplantation (d)	119	379	0.001
1-y freedom from treated rejection (%)	80	93	0.09
1-y freedom from infection (%)	60	80	0.09

 

Only one of the three fatal infections could be firmly attributed to donor-heart transmission. One heart recipient died of coccidioidomycosis within one month of transplantation, “which was retrospectively identified in the donor,” Lockhart said. In neither of the two other infection-related deaths, one from pneumonia associated with a vancomycin-resistant Enterococcus and the other from Escherichia coli urosepsis, could the infection be traced to the donor.

The two other recipients of homeless-donor hearts died from the consequences of rejection but showed no evidence of infection.

Since only one of the homeless-donor recipient deaths could be attributed to “donor consequences,” the analysis doesn’t really show that infections from homeless heart donors cause an increase in recipient mortality, according to Davis. “We really should be very cautious and try to identify whether this is a true relationship or if this just happens to be a statistical phenomenon.”

But he said the study does raise the question of whether more can be done at the OPO level to screen for such infections, “so you can initiate appropriate prophylactic therapies.”

Certainly there are blood tests for infections, Lockhart said to heartwire , “but often they’re not back by the time we actually implant the organ; it may be a retrospective finding.”

Currently, potential heart recipients are told whether the donors were IV drug abusers or prostitutes, “but we do not have to disclose that they were homeless, living on the street,” she said. “I think the patients do have some rights to know what kind of donor [the heart is from].”

Neither Lockhart nor Davis had disclosures.

References