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Discordant Serology and Nucleic Acid Testing Results for HIV, HBV and HCV in 2010

Nicole Theodoropoulos1,3, Marek Nowicki4, Claudia Chinchilla-Reyes4, Carol Pancoska5, Andres Jaramillo6, Tom Mone7, Rick Hasz8, Martin

D. Jendrisak6, Daniela P Ladner2,3, Michael G Ison1-3

1Divisions of Infectious Diseases and 2Organ Transplantation, 3Northwestern University Transplant Outcomes Research Collaborative, Northwestern University, 4Mendez National

Institute of Transplantation, 5Labs Inc, 6Gift of Hope Organ & Tissue Donor Network, 7OneLegacy, 8Gift of Life Donor Program

American Transplant Congress – Boston, MassachusettsJune 3, 2012

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Disclosures

• I have no financial relationships to disclose within the past 12 months relevant to my presentation.

• I do not intend to reference unlabeled/unapproved uses of drugs or products in my presentation.

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Background: Significant Organ Shortage

Organ Transplants (2010) 28,663

Current Waitlist Candidates 114,425

Deaths on Waitlist (2010) ~10,000

*Waiting list deaths includes removals for death, too sick to transplant, and those non-transplanted removals identified to have died within seven days of removal from linkage to SSDMF data. Based on OPTN data as of April 16, 2010.

http://optn.transplant.hrsa.gov/

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Background: Donor Screening Policy• OPTN Policy 2.2: Donor Evaluation

o Requires OPO to: Obtain a medical & social history of the donor Review the donor’s chart Perform a physical examination of the donor Perform FDA licensed, approved, or cleared screening tests

• Serology for: HIV, HCV, HBsAg, HBcAb, CMV, EBV, and syphilis• Additional testing may be done at the discretion of the OPO or accepting

transplant center

• OPTN Policy 4.1: Screening Donors for HIVo Prohibits the use of donors with + HIV test resulto Defines a donor at “increased risk of HIV, HBV or HCV transmission”

OPO must inform transplant center if the donor is increased risk Transplant Center must obtain special consent from the recipient to use

organs from an increased risk donor

http://optn.transplant.hrsa.gov/policiesAndBylaws/policies.aspRogers et al. MMWR. 1994; 43(RR-8):1-17.

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Background: Nucleic Acid Testing (NAT)• NAT can detect recent infection

• NAT increasingly used for donor screening3,4

Window Periods by assay type1,2

1Kucirka L et al. Am J Transplant 2011;11(6):1188-200.2Kucirka L et al. Am J Transplant 2011;11(6):1176-87.

3Orlowski et al. Am J Transplant. 2009; 9: 555.4Thedoropoulos N et al. Abstract LB17. ATC 2012.

Virus Serology NATHIV 22 days 9 days

HBV 44 days 22 days

HCV 66 days 7 days

Year HIV NAT HBV NAT HCV NAT

2008 78% of OPOs 34% of OPOs 78% of OPOs

2011 93% of OPOs 75% of OPOs 95% of OPOs

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Background: Nucleic Acid Testing (NAT)

1Humar et al. Am J Transplant. 2010; 10: 889-899.

• Recent Consensus Conference reviewed issues related to use of NAT for donor screening1

o Estimated the impact of false positive testingo Recommended NAT screening of increased risk donors

and those with inadequate risk information only

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Study Objectives

• To quantify the number of additional infections detected when NAT is added to routine serologic screening

• To attempt to quantify non-reproducibly positive NAT rates

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Methods: Sites & Serologic Screening

• Screening data on all potential deceased organ donors was obtained from 3 US OPO-affiliated laboratories in 2010, representing:o 15 Organ Procurement Organizationso ~35% of the US Donor Pool

• All potential deceased organ donors were screened for HIV, HBV, and HCV according to current OPTN Policyo Genetic Systems HIV-1/HIV-2 plus O EIA (Bio-Rad Laboratories)o Genetic Systems HBsAg EIA 3.0 (Bio-Rad Laboratories)o ORTHO HBc ELISA Test System (Ortho-Clinical Diagnostics, Inc.)o ORTHO HCV Version 3.0 ELISA Test System (Ortho-Clinical

Diagnostics, Inc.)o All assays performed according to the package insert

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Methods: NAT Screening

Lab A Lab B Lab CYear Initiated NAT 2008 2008 2004

Average NAT Volume

2 donors/week 33 donors/week 23 donors/week

Assay System PCR PCR TMA

Donors Screened All OPTN-defined increased risk

donors

All potential deceased organ

donors*

All potential deceased organ

donorsConfirmation None confirmed At request of

clientAs part of TMA

assay

• Polymerase Chain Reaction (PCR) Assayso COBAS Ampliscreen HIV-1 Test Version 1.5, Roche Molecular Systemso COBAS Ampliscreen HCV Test Version 2.0, Roche Molecular Systemso COBAS HBV Ampliscreen, Roche Molecular systems*

• Transcription-Mediated Amplification (TMA) Assayo Procleix HIV-1/HCV Assay, Gen-Probe, Inc.

*HBV NAT performed for all PDOD from 4/5 client OPOs

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Results: Serologic Screening

• 22 donors positive for both HBsAg and HBcAb.

LabTotal

Screened HIV EIA + HBs Ag + HBc Ab + HCV Ab +A 387 1 0 19 11B 1,760 7 15 193 150C 1,830 2 22 134 88

Total 3,977 10 (0.3%)

37 (0.9%)

346(8.7%)

249(6.3%)

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Results: NAT Screening

Lab HIV NAT HBV NAT HCV NATA 54 0 54B 1,760 501 1,760C 1,810 0 1,810Total Screened 3,624 501 3,624

Total NAT Screening Volumes by Lab

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Results: HIV NAT Screening

HIV Serology + Serology -

NAT + 8 (0.2%) 10 (0.3%)

NAT - 1 (0.03%) 3,605 (99.5%)

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Results: HIV NAT Non-Reproducible Results

• 10 HIV seronegative donors with + NATo One PCR-based labo 2/10 NAT were repeated and were found to be non-

reproducibly positive (NRP)o The lab performed an extensive quality investigation

Examination of the equipment and lab by the assay manufacturer Re-training of lab technicians Technician monitoring Machine sterilization No definite root cause was determined Lab changed to a TMA NAT platform

• Lab C used TMA for NATo Built-in confirmatory stepo All initial NAT + results were confirmed by discriminatory assay

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Results: HBV NAT Screening

HBV Serology + Serology -

NAT + 8 (0.9%)* 0

NAT - 60 (12%)°  433 (86.4%)

*4 isolated +HBcAb; 4 +HBsAg and +HBcAb°56/60 were isolated +HBcAb

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Results: HCV NAT Screening

HCV Serology + Serology -

NAT + 173 (4.8%) 5 (0.1%)

NAT - 64 (1.8%)  3,382 (93.3%)

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Conclusions

• NAT was positive in 15 (0.4%) seronegative donors• All HIV antibody negative/NAT positive results resulted

from one PCR-based labo 20% were shown to be non-reproducibly positive o Built-in confirmatory step in the TMA NAT may account for

fewer NRP results seen with this assay1

• Rapid and robust quality assurance is key• 1.8% PODs screened were HCV Ab+/NAT –• 12% PODs screened were HBV Ab+/NAT –

o HBV Ab + and HCV Ab+ donors have variable utilization2,3

o The use of NAT screening could improve utilization of HBV Ab + and HCV Ab + donor organs

1 Chinchilla-Reyes C et al. Abstract 387. ATC 2012.2 Kucirka LM et al. Am J Transplant 2010 May;10(5):1238-46.

3Taylor RM et al. Transplant Proc 2010;42:4479-87.

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Future Directions

• We intend to ask OPOs to share their primary donor screening data

• We plan to link this data with OPTN donor data to determineo The true incidence of seronegative, NAT positive donorso The effect of NAT screening on organ utilizationo The false positive rates of NAT in the deceased organ donor

populationo The effect of the type of NAT assay (PCR vs TMA) on false

positive results

• All donor screening results should be collected in a national database

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Questions?

Nicole Theodoropoulos, MD312-695-5054

n-theodoropoulos@md.northwestern.edunicoletheo15@gmail.com