Guidance

Chapter 14: clinical conditions present at the time of death

Updated 21 May 2024

Conditions which may not necessarily be due to infection require careful consideration.

Hepatitis

Infectious hepatitis may be due to viral (hepatitis A to E viruses, cytomegalovirus (CMV), Epstein-Barr virus (EBV), Yellow fever), bacterial (legionella, leptospira, coxiella) and protozoal (toxoplasma) infections. Some cases of hepatitis are non-infectious.

The presence of a hepatotropic pathogen is not in itself an absolute contraindication to donation but careful consideration is required.

Donation for liver transplantation may be undertaken depending on the pathogen involved, the presence or absence of chronic liver disease in the potential donor and the recipient need for transplantation. Liver allografts may be used from individuals who have HBV and HCV infection.

Acute liver failure due to pathogen:

• is a contraindication to liver transplantation
• is a contraindication to solid organ transplantation (other than liver) unless life preserving

Specialist microbiological advice must be sought.

Careful consideration of benefits from transplant is required.

Lower respiratory tract infection

Acute infection is a relative contraindication to lung transplantation. Individual assessment is required.

Bacterial infection (not tuberculosis (TB), if localised to lung, is not an absolute contraindication but advice regarding bacteraemia and drug resistant bacteria pertain for both solid organ and tissue donation.

Blood stream infection

Where an organ donor has had a positive blood culture in the 5 days preceding the donation but there is no visible damage or local infection in the organ at retrieval, donation of an organ may be acceptable with appropriate recipient prophylaxis. See the decision tree in figure 1.

Tissues should not be retrieved from a donor who has been found to be bacteraemic until after clinical recovery. If a risk assessment of the organisms isolated has been undertaken and is unlikely to represent a hazard to the recipient, tissues may be retrieved. Specialist microbiological advice must be sought.

Bacteraemia is not considered a contraindication for corneal donation provided the corneas are stored by organ culture at 28°C to 37°C where there is a greater opportunity to detect bacterial contamination and where the antibiotics in the organ culture medium are more effective than under hypothermic storage conditions.

Gamma irradiation offers a method for tissue sterilisation for those tissues able to withstand this process.

Figure 1: Decision making in potential donors with possible blood stream infections

Meningoencephalitis

The following decision tree (figure 2) details the approach to the donor where central nervous system infection exists or should be considered to exist.

If bacterial meningitis has been confirmed, and there is no visible damage or local infection in the organ or tissues required at retrieval, the donation of the organs, tissues and cells are acceptable provided appropriate treatment has been administered to the donor.

Appropriate antibiotic prophylaxis covering any organism isolated from the donor should be considered for identifiable recipients, especially in the case of organs.

Material from cases of death from meningoencephalitis where no organism is cultured should not be used for donation, except in the circumstance that the following conditions are met:

• the infection is thought due to a bacterium by clinicians caring for the patient
• microbiological cultures are negative because they were taken after antibiotics had been started
• appropriate and adequate antibiotic treatment has been given to the recipient
• expert microbiological advice has been obtained

A travel history should be obtained. Donation is contraindicated if there is any possibility of acquisition of a neurotropic infection from abroad due to the potential for rabies virus, West Nile virus or other geographically restricted neurotropic infections.

History of close occupational or other animal contact should be explored because of the risk of zoonotic infection.

Herpes simplex virus (HSV) or varicella zoster virus (VZV) central nervous system infection is diagnosed as a manifestation of systemic viral infection (as seen in neonates and the immunosuppressed). Donation of organs, tissues and cells is contraindicated as the viruses may be disseminated widely with associated viraemia.

HSV encephalitis without evidence of systemic infection can be treated with antiviral therapy and the likelihood of disseminated infection in the donor is small, even without antiviral therapy. In this situation antiviral prophylaxis should be considered for the organ recipient.

Organs can be considered for donation if local HSV or VZV infection has been treated with adequate antiviral therapy for more than 7 days. If treated for less than 7 days, the recipient should receive antiviral prophylaxis. Serological status of the recipient may also inform a risk and benefit analysis.

Eyes must not be donated if the donor has active or a past history of HSV or VZV keratitis.

Figure 2: Decision making in potential donors with meningoencephalitis

Myocarditis

Myocarditis may be due to a number of causes including infections.

There is the potential for transmission of infection where myocarditis is due to a pathogen. However, there is limited available data regarding risk of transmission.

Careful consideration of benefits from transplant is required.

In organ transplantation:

• myocarditis in the donor is an absolute contraindication to cardiac transplantation
• current myocarditis in the donor is a relative contraindication for other allografts

Current myocarditis is an absolute contraindication to tissue donation unless the transplant is life preserving.

Specialist microbiological advice must be sought.

See a list of all chapters in this guidance