High infectious risk donors: what are the risks and when are they too high?

High infectious risk donors (HRDs) fall into a behavioral category thought to increase risk of infectious transmission through transplantation; despite controversy surrounding their use, they comprise almost 9% of donors in which at least one organ is recovered. This review seeks to describe national patterns in utilization, attitudes toward HRDs, and strategies to minimize and quantify infectious risks.

HRD organs are discarded at a higher rate than non-HRDs, and many surgeons have decreased the use of HRDs in response to a recent widely publicized case of HIV and hepatitis C virus (HCV) transmission. Special informed consent use can mitigate legal risk and might increase provider comfort with HRD utilization. Nucleic acid testing (NAT) mitigates infectious risk by decreasing the window period, particularly for HCV in which the risk of undetected window period infection decreases by an order of magnitude. Estimated risk of undetected window period HIV infection varies by HRD behavior category (range 0.035-4.9 per 10,000 donors when NAT is used), HCV risk is higher (range 0.027-32.4 per 10.000).

Given long waiting times and high waitlist mortality, organs from HRDs can be used to expand the organ supply. Estimates of HRD infectious risk can be used to guide patient and provider decision making.