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Infected kidneys suspected in rabies deaths of transplant patients in China
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Researchers in China suspect that two kidney transplant recipients died after they were given organs from a deceased donor infected with rabies.
Two other patients received transplanted corneas from the organ donor, a boy aged 6 years, but both survived after receiving rabies prophylaxis. The researchers said their findings — including that the donor frequently was exposed to dogs and symptoms of the disease — led them to the conclusion that the kidney transplant recipients died from rabies that was transmitted through the infected organs, although they were unable to prove it.
“Further confirmation could not be done because the donor, who was diagnosed with infectious encephalitis, was cremated after organs and tissues were collected for transplantation, and no clinical specimens were kept by the hospital,” the investigators wrote in Emerging Infectious Diseases. “Thus, we could not confirm rabies in the donor by laboratory methods.”
No autopsy performed on donor
The boy lived in an area of the country, Guangxi, that reported the highest number of cumulative rabies cases from 2004 to 2014, according to the researchers. His symptoms began on May 13, 2015, and grew worse within 2 weeks, resulting in a coma and loss of all physiological and pathological reflexes. He was treated at several hospitals and diagnosed with possible viral encephalitis.
Before he died on May 26, the boy was tested for HIV, hepatitis B virus and syphilis according to Chinese organ donation laws, and he tested negative for all three. No autopsy was performed, and no specimens were kept for testing, the researchers wrote.
On May 27, two uremia patients received the deceased child’s kidneys in allograft transplants.
Investigation leads to rabies conclusion
After an initially normal recovery period, the first patient, a male aged 55 years, began experiencing symptoms 42 days after receiving the kidney. He was hospitalized 2 days later and was diagnosed with suspected rabies infection on July 24. The diagnosis was confirmed on July 28 and the man died on Aug. 23 — 46 days after the onset of his symptoms and 88 days after the transplant surgery.
The second patient, a male aged 43 years, also had a normal recovery until he began experiencing symptoms on July 14, 48 days after the surgery. He was admitted to the hospital 4 days later and diagnosed with suspected rabies infection on July 24. Like the first patient, the diagnosis was confirmed 4 days later on July 28. The man died on Aug. 17 — 34 days after his symptoms first appeared and 82 days after the transplant surgery.
The two patients who received corneal transplants were given full rabies post-exposure prophylaxis (PEP) on Aug. 6 after it was confirmed that they had received their transplants from the deceased boy. As of Feb. 2, both were reported to be in good health.
According to the researchers, the kidney transplant recipients tested positive for rabies by RT-PCR. Their families said neither patient had pets nor a history of animal bites or scratches. The boy’s family kept dogs for many years, and he had frequent contact with them, the researchers reported. However, he had been living in another city with his grandmother, who did not recall the boy being bitten by any animals.
Rabies is not covered under Chinese laws governing the testing of donor organs and is difficult to diagnose in the short window of time for transplantation, the researchers said. To decrease the transmission of infectious diseases such as rabies through organ transplantation, the researchers recommended improvements in the testing of donors in China.
“In addition,” they wrote, “health education should be improved to enhance public awareness of possible transplant-associated infectious diseases. If it is determined that organs or tissues from a donor with rabies have been transplanted, the transplant recipients and other exposed persons who are at risk must receive consistent health monitoring and follow-up, including rabies PEP, and any remaining organs and tissues must be quarantined and not transplanted.” – by Gerard Gallagher
Perspective
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Peter Chin-Hong, MD, MAS
Donor-derived rabies transmission has been well-described, but fortunately still rare. In the case of donors with acute encephalitis, as in this Chinese donor, transplant professionals often pause — there have been cases of West Nile virus, lymphocytic choriomeningitis virus, Balamuthia amoeba and rabies transmitted this way. It is also challenging to rally appropriate diagnostics to reassure transplant centers when snap decisions must be made. Although I would certainly not advocate denying organ donation from patients who only have nonspecific risk factors for these rare infections, acutely ill potential donors with unexplained neurological processes may tip the risk-benefit ratio unfavorably. This is particularly true for nonfulminant recipients such as kidney and cornea patients (as in this report) who rarely have an acute need for transplantation. We have made great advances in identifying donors at risk of and consenting recipients appropriately for the “big 3” — HIV, hepatitis B and hepatitis C. However, we continue to grapple with appropriately understanding risk and how best to counsel patients contemplating organs from donors with encephalitis. Systematic collection, storage of donor specimens and postmortem diagnostics in cases like this will increase our understanding and substantially improve our ability to discuss risk with the most important stakeholders: our patients.
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