Risk of AIDS Poses Threat for Transplant Recipients

During the early morning hours of Aug. 16, a 30-year-old man was severely injured in a North Carolina auto accident. Rushed to a Greensboro hospital, he was transfused with more than eight quarts of blood--nearly twice his body volume--as physicians worked desperately to save his life. But 72 hours later their efforts ended in failure.

Then, in what has become an increasingly common sequel to such sudden deaths, his family was persuaded to donate his organs. A battery of tests, including one for AIDS infection, all gave green lights, and quickly one of his kidneys was transplanted into a seriously ill man in Georgia and his liver was given to a recipient in Pittsburgh.

Several months later, to their horror, medical authorities found that both recipients had been exposed to the AIDS virus, although neither had yet developed the deadly disease’s symptoms. The source appeared to be the organs from the auto accident victim in North Carolina.

The North Carolina case vividly demonstrates how AIDS, which renders an individual’s immune system powerless against otherwise rare infections and cancers, has presented particularly knotty problems for the organ transplant community.

The AIDS danger now looms over all organ transplants, especially since young adults make up the majority of AIDS cases and young adults killed in accidents or in other violent deaths are the major source of organs. In 1985 alone, nearly 9,200 organ transplants and more than 26,000 cornea transplants were performed in the United States.

To be sure, the North Carolina case remains one of only a few known instances so far of AIDS transmission through organ transplantation. But for physicians, organ procurement groups and families of both donors and recipients--for everyone involved in procedures where organs are scarce, life often hangs in the balance and every second counts--the mere possibility of AIDS has raised some troubling questions:

--Are there circumstances when it is not possible to test a potential organ donor for AIDS?

--Are there emergencies in which an infected organ should be used?

Who Gets Transplants?

--Should individuals already infected with the AIDS virus be entitled to receive organs, or is the procedure wasted on those who may eventually die from the disease?

--Should a donor’s family be told that the dead relative is to be tested for AIDS--and should the family be informed of the test results?

To protect recipients, the Public Health Service has recommended that every donor be tested for exposure to AIDS before organs are taken or used and that persons most likely to have AIDS--such as homosexual and bisexual men, intravenous drug users and their sexual partners--agree not to donate their organs. Federal health officials believe that virtually every organization involved in transplants is using the test.

Dr. Robert T. Schooley, who treats AIDS patients at Massachusetts General Hospital in Boston, believes it is virtually always possible to test organ donors’ blood for the AIDS antibody.

Widespread Testing Urged

“When they fail to test a donor, it’s not because they can’t but because they have made an error in judgment or don’t want to be bothered,” he said. “I can imagine very, very few situations in which it is impossible to do the test.”

But there are situations, said Dr. Harold Jaffe, chief of the epidemiology section of the federal Centers for Disease Control’s AIDS program, in which performing the test, which usually takes several hours to yield results, could be extremely difficult.

“You could have a logistical problem getting the test done quickly,” he said. “Although you can get the test results in a couple of hours, I imagine there could be a problem, for example, with a gunshot victim coming in the middle of night, or if you’ve got a dying recipient. If you have a recipient who can afford to wait, that’s one thing. But if he’s dying and it’s a good tissue match, you might take a chance and do it.”

Dr. David Weber, assistant professor of medicine, pediatrics and epidemiology at the University of North Carolina at Chapel Hill, agreed. Like Jaffe, he strongly advocates testing but says that there may be situations where it is not possible.

“Hearts and livers only remain viable for two to four hours at most--and that’s really pushing it,” Weber said. “So you’re already talking about a severe press for time in terms of getting the test done. Do you throw the organ away if you can’t test it? Nobody would transplant an organ if the donor is known to have AIDS. But what do you do if you don’t have the time or the facilities to test?”

Four Documented Cases

Although instances of AIDS transmission through organs are rare, four cases have been documented in West Germany, where the donors were never tested but had been intravenous drug users, an AIDS high-risk group.

In this country, the first known case occurred in 1982, before testing was available, when an infected homosexual man donated a kidney to his sister and she later developed AIDS and died. There have also been instances in which tainted organs were transplanted and the recipients thus far have not developed antibodies to the virus.

“There is no question you can transmit AIDS with a transplanted organ,” said Dr. Robert Rubin, chief of the transplant infectious diseases service at Massachusetts General Hospital, who is compiling an international registry of information on AIDS and transplants. “It can be a disaster, a tragedy--and it’s something that is almost totally preventable.”

In the North Carolina case, medical experts now believe that the large amounts of blood given to the donor had probably diluted the presence of AIDS antibodies, causing the test to produce a false negative.

As a result, however, the Southeastern Organ Procurement Foundation, whose members include the facility that obtained the infected organs, has adopted a policy to permit transplants in life-or-death situations without knowing the AIDS test result--a decision that has upset many involved in organ transplantation and patient care.

‘How Would You Feel?’

“It makes me very anxious,” said Dr. Timothy Lane, chief of the internal medicine training program at Moses Cone Hospital in Greensboro. “Everyone hearing that could personalize it--how would you feel getting an infected organ? I think anybody would feel anxious.”

Still, some medical experts say they envision situations where an organ procurement group may shy away from questioning a donor’s next of kin about homosexuality or intravenous drug use, or where a family might not know the answers. In the North Carolina case, for example, the donor’s family denied that he was gay or that he had ever used intravenous drugs, and his source of infection remains undetermined.

And sometimes, said Dr. G. Baird Helfrich, director of the division of transplantation at Georgetown University Hospital here, an AIDS-infected organ might be the only one available.

Helfrich said that his facility observes strict safeguards to protect against transplanting infected organs. Georgetown began testing donors in April, 1985, when the procedure became available.

“But what if you have a 30-year-old male with a 1-year-old and a 3-year-old at home. He will die in one hour if he doesn’t have a heart transplant. He has a choice: He can take an AIDS heart or die. It’s a heck of a choice. But if the choice is whether he can see his children go from 1 and 3 to 5 and 7 or he can die, many people would accept the heart.”

Contamination Risk High

Carol Levine, a medical ethicist with the AIDS project of the Hastings Center in Hastings, N.Y., agreed. “You would want the patient to be informed of that alternative and have that choice. I think most people would choose the real but not immediately lethal risk over certain death. The risk of contamination is high, but it isn’t 100%.”

But Schooley of Massachusetts General said that in Helfrich’s hypothetical case, there would be alternatives other than the AIDS heart and certain death.

“I think it would be a mistake to use that heart,” he said. “There are now ways to bridge these gaps that make these ‘one-hour life-and-death’ situations more of a theoretical discussion. If you have a patient that unstable, he usually isn’t a great candidate for heart transplantation anyway. And increasingly, artificial hearts are being used to keep people alive for short periods of time until a heart can be procured.”

A different dilemma confronting the transplant community is whether an individual infected with the AIDS virus should be given a transplanted organ, especially when there is a scarcity of organs.

Massachusetts General faced that question last year in deciding whether to transplant a liver into a 32-year-old man suffering from liver failure. He was also infected with the AIDS virus but had not yet developed the disease, although statistics suggest that at least 30% and possibly many more of those with the virus will ultimately contract the symptoms.

‘Do We Let Him Die?’

“The issue was: Do we let him die or transplant him?” Rubin said. “We transplanted him more than a year ago--and he is doing well.”

Helfrich of Georgetown University suggested that one solution may be to transplant infected organs into infected people. “It’s conceivable that AIDS-positive donors could be utilized to transplant AIDS-positive recipients, instead of throwing things out,” he said. “We have a responsibility to everybody in need.”

Schooley opposed transplanting an organ from someone who had died of AIDS into the body of someone who has the virus but not the disease. There is an additional danger, he said, of transmitting one of the opportunistic infections that commonly strike AIDS patients.

Levine of Hastings said that any such decision “should be based strictly on whether the transplant would benefit the person.”

“I don’t think there should be any discrimination based on ‘this person is not going to live long anyway,’ ” she said. “If the organ will benefit the person, I say: ‘Yes, do it.’ ”

While medical facilities almost universally agree that the AIDS test should be performed on organ donors, they differ on what they tell the donors’ families about what tests are performed, and what the test results are. Many feel it is imperative to inform family members--particularly the spouse or sexual partner--of a donor’s positive AIDS test result.

Clear-Cut Responsibility

“The responsibility is very clear cut,” said Lane, of Moses Cone. “The spouse needs to be informed because her health is at risk, and she could spread the infection.”

It is also unclear whether procurement teams have been as vigilant as federal guidelines recommend in asking family members whether donors are in high-risk groups for AIDS. At Georgetown University Hospital, according to Helfrich, family members of donors are always questioned about homosexuality and intravenous drug use.

“I think you have to ask those questions, but in an appropriate way,” he said. “We have an obligation to the tens of thousands of people who need these organs.”