UA-184069179-1 117: They Paged Me What? A TID Guide to Donor Call - Febrile
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Episode 117

117: They Paged Me What? A TID Guide to Donor Call

Drs. Chelsea Gorsline, Courtney Harris, and Rebecca Kumar join to tell us more about the Transplant ID Early Career Network and how to approach donor call!

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Febrile is produced with support from the Infectious Diseases Society of America (IDSA)

Transcript
Sara Dong:

Hi everyone, welcome to Febrile, a cultured podcast about

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all things infectious disease.

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We use consult questions to dive into

ID clinical reasoning, diagnostics,

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and antimicrobial management.

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I'm Sara Dong, your host

and a MedPeds ID doc.

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I have three guests with me today,

I'm super excited to introduce.

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I'll start with Dr.

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Chelsea Gorsline.

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Chelsea is a transplant ID physician and

assistant professor at the University

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of Kansas Medical Center in Kansas City.

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She completed her internal medicine

residency, general and transplant

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ID fellowship training at Vanderbilt

University Medical Center in Nashville.

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Chelsea Gorsline: Hi,

I'm Chelsea Gorsline.

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Sara Dong: Next, we have Dr.

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Courtney Harris, who is a transplant

ID physician and assistant professor at

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the Medical University of South Carolina

in Charleston, which is my alumni.

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She completed her residency and chief

residency at Mayo Clinic in Minnesota,

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followed by general and transplant

ID fellowship at the combined program

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of Brigham and Women's Hospital and

Massachusetts General Hospital in Boston.

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Courtney Harris: Hey,

this is Courtney Harris.

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Sara Dong: And our third

member today is Dr.

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Rebecca Kumar.

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She is a transplant ID physician and

assistant professor at MedStar Georgetown

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University Hospital in the Division of

Infectious Diseases and Tropical Medicine.

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She completed her internal medicine

residency at MedStar Georgetown

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University Hospital in Washington, D.

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C.,

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followed by fellowship

in infectious diseases at

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Northwestern University in Chicago.

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Rebecca Kumar: Hey, this is Rebecca.

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Sara Dong: Welcome.

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So as everyone's favorite cultured

podcast, we like to kick off the

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episode by asking you to share a

little piece of culture, something

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that you've enjoyed recently.

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Chelsea Gorsline: I can go first.

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Uh, I, if I wasn't in medicine,

I would be in the arts.

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So I couldn't pick one

thing, but I picked two.

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So, uh, my favorite band

right now is Fontaines DC.

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They're from Ireland.

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They're like a proper rock band.

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I'm obsessed with the lead singer's voice.

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It's so great.

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The lyrics are poetry.

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I love the music.

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I got to see them last year and I'm

going to see them again next month and

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I'm just really really excited for it.

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And then the second thing is, uh,

totally obsessed with the TV show

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Severance on Apple TV right now.

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Cannot get enough of it.

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A psychological thriller, a little

bit of a workplace comedy, a little

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bit of sci fi, just incredible.

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Front to back, my husband and I

cannot stop reading theories about it.

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It's just such a great time.

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Sara Dong: Severance is so good, and

I haven't had anyone to talk to about

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it, and it's been driving me crazy.

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Courtney Harris: So good.

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It's amazing.

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Chelsea Gorsline: So good.

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Courtney Harris: So I can go next.

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My sister introduced me to fantasy

books as well as Chelsea on this call.

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Um, and so I am currently starting

the seventh book of the Throne

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of Glass series, which has

been a slog and it is amazing.

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It's a, like a fantasy novel series

following like a teenage assassin

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trying to take down a corrupt

kingdom with a tyrannical ruler.

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Like it's wonderful.

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So I'm very excited to like

finish this series out strong.

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Chelsea Gorsline: Great series.

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Rebecca Kumar: Um, the piece of

culture that I'm really enjoying

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right now is White Lotus.

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At the time of recording, I think

the third episode has just aired,

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I'm also obsessed with like reading

fan theories online and trying to

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figure out what the deal with Rick is.

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Sara Dong: Yes!

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Rebecca Kumar: So that's really what's

been occupying my time off service.

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Sara Dong: Oh, this is so great.

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Now everyone can see

why I invited you guys.

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We have such shared cultural interest.

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Uh, well, today is a fun episode.

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As an also, uh, young or junior transplant

ID doc, I've been, uh, excited to

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meet you guys and have been following

along with the Transplant ID Early

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Career Network and efforts from that.

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And so before we talk through the

goal of the episode today and some of

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our consult questions, I was hoping

actually you could tell people about the

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network in case they aren't familiar.

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Chelsea Gorsline: Yeah.

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So I founded the Transplant ID Early

Career Network during the pandemic, was

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really lonely time I think for all of us.

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Really is a way to do virtual

networking for trainees who were

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interested in transplant ID.

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And then a couple of years ago, when

I transitioned to faculty at KUMC,

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I recruited help from Courtney and

Rebecca, and really we wanted to

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expand the scope of what this was able

to offer, not just for trainees, but

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also for early career faculty as well.

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And with Courtney's help, we really

introduced a lot of new medical

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education activities, which a lot of

this has been based on social media.

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And then we've subsequently formed

a partnership with the Transplant

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ID Journal, and we've published

numerous papers now, mostly with

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practical pragmatic tips for trainees

and early career faculty that are

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really based off of these activities.

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And now we are starting to

transition into doing more in

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person live events at conferences.

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So be on the lookout for those in 2025.

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Sara Dong: Love it.

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And we're going to put

links to those papers.

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So a large portion of our job in

Transplant ID is giving advice

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on risk of infection related to

organ transplantation, and one

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part of that is something that

most people call donor call.

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So when a surgeon or a transplant

coordinator or someone from the

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transplant team calls and asks about the

suitability of an organ for transplant.

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I want to highlight one of those

articles that you mentioned that has

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come out through the Early Career

Network, and we're going to walk

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through some scenarios today to give

examples of the thought process.

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Maybe before we give a clinical

example, you can talk a little bit

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about donor call in general for those

who maybe aren't used to participating.

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Chelsea Gorsline: Yeah, so this

is when a surgeon or a transplant

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coordinator will call and ask about the

suitability of an organ for transplant.

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So when I was a transplant fellow, I

would occasionally field these calls

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and then sometimes would discuss

them when my attending would receive

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them, but I never received formal

training on how to approach these.

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And actually my colleague, Rachel

Sigler, she worked pretty hard to

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develop a mock donor call educational

activity while she was a fellow.

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And we loved this idea.

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We really wanted to collaborate with

her and build on what she started so

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that others could actually use this

as a template if they're also trying

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to teach this in a structured setting.

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Courtney Harris: So what we ended up

doing from the Early Career Network is we

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created a series then of five donor call

examples and posted one example, like

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donor call scenario to social media in

the morning at that time we were using X

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or Twitter, and then over the course of

the day, let the transplant ID community

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kind of comment on what they would do, and

then in the evening posted the resolution

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to the case with some teaching points,

so we saw a lot of engagement with this

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approach, and many followers commented

daily, like, and it was nice to see kind

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of that wide variety of approaches and

how people approaching so differently.

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Things that are standard, you

know, dosing is different, how

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long you treat is different.

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So it was really nice to kind of see, you

know, some of the really great leaders

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in our field have different approaches to

donor calls, which I think really shows

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the variability , which is why it's always

good to discuss these with our trainees.

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Chelsea Gorsline: Yeah, and something

that we felt really strongly about when

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we wrote the paper was that we really

wanted to develop a framework to help

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trainees and early career faculty think

about how to prepare for these calls.

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And so this would include what are the

appropriate follow up questions to ask

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and what are the important non infectious

considerations that you should be

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thinking about when you accept a donor?

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Rebecca Kumar: And I think key among

them is just this idea that there's a

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risk to the recipients if we keep them

on the waitlist for longer, waiting for

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that perfect, absolutely perfect organ.

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So I think weighing that risk of a

possible donor derived infection with

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the risk associated with mortality

on the waitlist is really what's a

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key driving principle in donor call.

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Courtney Harris: I think one of the other

things about donor calls, too, is it's

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very easy to get flustered when you're

on the phone, like answering questions,

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so it's good to have a really stepwise

approach, especially when they may be

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giving you really minimal information,

but you want to think about it the

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same way every time you approach it.

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So if you check out our paper,

Table 1, there's really good steps

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to how to consider these offers

in a, you know, stepwise manner.

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So you ask donor specific questions

like their medical, social history,

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any recent micro, their hospital

course for the donor, then recipient

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specific questions like, you know,

what kind of immunity do they have?

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What vaccines have they received?

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What kind of underlying medical

conditions do they have?

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And then, you know, what

is the transmissibility?

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So in, for example, a donor

has a urinary tract infection.

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Is the transplanted organ

the kidneys or the heart?

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Cause that matters.

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Um, and then has the donor been treated?

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So what's the treatment of the donor

and then can you treat the recipient?

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And then finally, what is the likelihood

of future offers and the mortality?

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So, is the recipient going to be a heart

transplant who's on temporary mechanical

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support and has a high mortality in the

coming days and has a low likelihood of

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receiving another offer, then, you know,

maybe there is a risk, but maybe that risk

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is much lower than them having a fatality

on the waitlist waiting for another offer.

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So I think that's kind of our

stepwise way to approach them.

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Sara Dong: Perfect.

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All right.

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Well, you guys, we have the pager or the

cell phone, whatever people are using.

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I'm going to go through a

couple of donor calls today.

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So I'll start with call number one.

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You receive an offer for a liver

transplant from a donor in Georgia.

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The donor is a 35 year old

previously healthy woman who was

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hospitalized after injuries related

to trauma from a car accident.

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Encephalopathy was noted during

the hospitalization, and she was

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subsequently declared brain dead.

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There were some varying reports

from family on the preceding

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symptoms before this happened.

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So maybe fever, maybe she'd been

more tired and fatigued recently.

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There was no fever documented during the

hospitalization and the labs on admission

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were not suggestive of infection.

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So what questions do you have?

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Rebecca Kumar: I think one of the hard

things about donor call is just the fact

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that in, in essence, it is essentially

a game of telephone where you get the

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information from somebody else who's

gotten it secondhand from a family

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member who may or may not know everything

about what's going on with the donor.

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So one of the key things that I'm thinking

about when I hear the coordinator call

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and mention that there's encephalopathy

is what, what's the underlying

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cause of this altered mental status.

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And anytime there's an unknown etiology, I

think one of the big things that we almost

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always recommend is a lumbar puncture.

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And really, in a patient who's presenting

with fever and altered mental status,

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you want that lumbar puncture before

you accept the organ because we really

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don't know if there's possibly some sort

of viral, um, meningitis or something

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else that could be easily transmitted

from the donor to the recipient.

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Um, and so, and I didn't quite catch,

sorry, what time of year did this happen?

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Sara Dong: It's summertime.

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Rebecca Kumar: It's summertime.

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So I think one of the big things

that we'd be worried about would

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be something like West Nile.

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Um, and then the other things that you

need to consider when you're assessing

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the donor is where's the donor from?

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So are there any outbreaks

ongoing in Georgia at this time,

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at this particular time of year?

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One of the things that we talk about

in our paper is related to the Fusarium

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meningitis outbreak that happened

in:

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to Mexico to get plastic surgery.

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Um, and another thing to consider at

time of recording is this big measles

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outbreak that's going on in the U.

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S.

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So all of these things are

considerations when we're assessing

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the suitability of this of this donor.

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So that's sort of the things that

I'm thinking about right now.

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So I would ask for this lumbar puncture.

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I would make sure because it's summertime

that we check for West Nile and get

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the cell count everything else with it.

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And based on the results,

we would make our decision.

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Because of the time of year, if

the lumbar puncture, if it cannot

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be done, I think that this would

be an organ that I would recommend

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declining because we don't know why the

patient's encephalopathic with a fever.

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Sara Dong: That's a take home that I

try and reinforce with fellows about

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unknown encephalopathy is, is quite

worrisome when you get a donor call.

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All right.

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Okay, perfect.

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And everyone should know that these are

sort of cases created for education,

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so they're not, um, fully fleshed out.

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We kind of just want to go through the

thought process of getting donor calls.

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So, all right, your pager goes off again

and you call them back and they say,

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we've received an offer for a kidney

transplant donor who we just found out

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has Enterobacter cloacae in the urine.

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The donor had a Foley catheter

in place and urine was collected

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from the Foley and is now growing

drug resistant Enterobacter.

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The sensitivities that we have so far

are cefepime MIC32, which is resistant,

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our pip-tazo is resistant, the meropenem

is susceptible the MIC is less than 0.

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5, ertapenem was intermediate with an

MIC of 1, and ceftazidime avibactam

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is sensitive with an MIC of 4.

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The donor has decreasing pressure

requirements and improving white

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blood cell count and creatinine, and

all vitals are within normal limits.

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They also have information that the

blood cultures from two days ago are

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negative to date, and the patient is now

on day two of meropenem for the isolate.

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So just wondering, what do you think?

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Are you worried about accepting?

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Chelsea Gorsline: Yeah, so this is a

pretty common scenario that we run into

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with our kidney transplant recipients.

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Because patients can have bacteria

in the urine, it's not necessarily

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a reason we should decline an organ,

but there are a few things that we

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would want to make sure that the

donor has been set up with and then

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appropriately treat the recipient as well.

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Um, so for the most part, we would want

patients or donors to have received

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at least 24 to 48 hours of appropriate

antibiotic therapy prior to procurement.

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And then looking at the recipient,

we would want to treat them

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with at least, you know, seven

or so days of targeted therapy.

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I think this can also vary depending

on what institution you work at and

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how long you will treat the patient.

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And also things like whether

there was bacteremia present can

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impact that duration as well.

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But I think this case is nice too

because it also highlights that you

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have to be familiar with resistance

patterns, not just the principles

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of how to treat a recipient.

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So for instance, in this case, the

Enterobacter is meropenem susceptible,

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but it's ertapenem intermediate.

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So in some cases that might give you

pause, but then if you Enterobacter

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species can actually have a low level

ertapenem monoresistance, and this doesn't

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necessarily preclude the use of meropenem.

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That makes this case a little bit more

approachable and easier to say, okay,

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we're going to go ahead and give the

recipient meropenem to treat them.

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And then we'll call out that the IDSA

has published some updates to their MDR

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gram negative treatment recommendations

in the past couple of years, so those

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can always be a great resource when

you're looking at tough cases like this.

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And then I know, at least at my

institution, we also have developed

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our own, uh, internal guidelines

on how to approach these organisms,

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so those can be helpful as well.

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Sara Dong: Excellent.

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All right.

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Well, we're getting another, another call.

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You get the message that our patient

who received a lung transplant last

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week is doing great, but we were

just informed that the donor had a

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positive Strongyloides antibody so,

do we need to do anything about this?

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Courtney Harris: So this case is a

little bit different since the patient

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has already received their transplant,

but donor derived infection with

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Strongyloides typically occurs, um,

within 90 days after transplant when

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immunosuppression is the highest.

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So here we're going to worry about

hyperinfection syndrome, which can

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impact the lungs and the GI tract and

can be devastating to recipients, the

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rapid larval migration and risk for

ARDS, GI bleeding can be severe and

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the mortality rate's up to 35 percent.

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So despite this, we can safely

accept organs from donors who

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have positive Strongy exposures

as effective treatment exists.

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It really isn't going to interact

with a lot of the other medications.

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So if a donor or recipient is

positive for Strongyloides, we

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can just go ahead and treat.

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Treatment, there's a little

bit of a debate about how

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many doses you need to give.

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You can either give two doses over

two days and whether that's enough

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or whether secondary dosing in two

weeks and repeating those two doses

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is necessary, but regardless, it's

recommended to give the recipient

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ivermectin, which again is well

tolerated with minimal drug interactions.

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And it's notable to that a positive

Strongy IgG in a pretransplant recipient

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doesn't give them any protective immunity.

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So even if they were treated pre

transplant for their positive

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Strongy, if their donor is positive,

I would go ahead and retreat then.

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Um, and while strongy is kind of

prevalent in Africa, Asia, Latin

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America is kind of the teaching.

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There are pockets of

endeminicity in the U.

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S.,

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um, especially in the Eastern U.

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S.

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So where I practice at MUSC in South

Carolina, a lot of our patients are

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living in rural South Carolina, and

we've actually like looked, there was a

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prior team that looked at this, um, Ruth

Adekunle from MUSC here, her and our prior

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team studied universal screening in our

heart transplants over a shorter period of

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time and found that our heart transplants

had near 11 percent Strongy positive.

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And a good percentage of our donors have

not had travel outside the United States.

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Um, so, you know, we're now actually

studying over a five year period of

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universal screening in heart transplant,

whether or not the rate is really

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this high, but I suspect that it is.

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And so because of this, we've

started screening all of our solid

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organ transplants for Strongy.

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So I think having an increasing vigilance

for this infection transmission in the U.

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S.

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is really important.

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Sara Dong: I love hearing what

other, other centers are doing

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and comparing and contrasting.

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That's awesome.

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Okay, well we have another call.

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Our fourth case here, the Lung Transplant

Coordinator calls to let you know that

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the OPO just notified us that the donor we

want to take has "fungus" in the sputum.

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The donor is a 45 year old

incarcerated man from California.

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He has a hemoglobin A1c of

14 but no smoking history.

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Cause of death was suicide.

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So, can we take this organ?

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The procurement team is

present and the recipient has

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just arrived at the hospital.

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And for additional information

on the recipient, it is a 24 year

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old patient with cystic fibrosis.

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Chelsea Gorsline: I think

this case is super fun.

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It's like doing a consult

just with a donor call.

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So this case really presses you to

know what the differential for fungus

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on a sputum culture is, and really

what other information do you need to

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obtain from the OPO to help you decide

if you should accept this organ or not.

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And so differential for fungus

is going to be broad, right?

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So there's endemic mycoses, there's

molds, there's yeast, but we would

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only want to accept this organ if we

know what the fungus is, and there's

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a good treatment option for it.

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So in this case, we asked the OPO, Hey,

can you identify what the fungus is?

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And they were not able to identify it.

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And so this organ would be declined

because we really just don't

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know what we're dealing with.

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Um, the setup for this case is that

the donor had Coccidioides, um,

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with risk factors being uncontrolled

diabetes, residence in California.

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And I think this is important because

Coccidioides, we do not have universal

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recommendations for donor screening.

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And so as someone who is getting these

donor calls, you really have to be

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mindful of where is the donor located?

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What are their radiographic findings,

which is available in the U.

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S.

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through UNET, and also other things

like ventilator settings or respiratory

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status of the donor which that

OPO can provide to you if you ask.

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And the reason that we care about this so

much is because donor derived infections

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with Coccidioides can also be very

devastating, um, disseminated disease.

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And so, if we knew that the donor

had Coccidioides, we really wouldn't

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want to be taking organs from them

unless we know that the infection is

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under control or hopefully cleared.

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But if we also knew that the donor had

a prior history of it, we could actually

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also give preemptive azole therapy to the

recipients to then prevent that risk of

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transmission and harm to the recipient.

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And then also if we do detect a case of

donor derived infection, then we would

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want all of the other recipients to be

treated for Coccidioides as well, just

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because this fungus is quite transmissible

and associated with high mortality.

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Sara Dong: And I realize I may have

said OPO earlier and never defined it

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otherwise, so, um, just to explain, OPO

stands for organ procurement organization.

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And so the last thing I want to do is

for us to have a transplant ID episode

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using acronyms and not explaining

them, especially because we're trying

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to shed some light on the behind

the scene aspects of transplant.

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So these are just a few example calls,

and it's a really big topic, but I

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hope at least people have a starting

framework on approaching donor call,

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and I wanted to see if you guys have any

other take home points that you'd like

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to share, whether that's about taking

donor call or donor derived infections.

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Rebecca Kumar: Even if after you take

donor call, everything seems fine that

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you should keep an eye out for possible

donor derived infections after transplant.

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This can happen, you know, the classic

teaching is anywhere from like in

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that first 30 days after transplant,

but we have seen issues with donor

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derived infections months after.

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We recently had a case of Bartonella

quintana endocarditis in our recipient

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who was completely asymptomatic,

but got it from his donor.

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And the only reason we found out

was because the other recipient

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was ill and the OPO was notified.

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And then we were able to screen our donor.

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Courtney Harris: And then I think another

key takeaway would be that, it's really

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important for anyone you're seeing that's

infected in the early or even like mid

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to late post transplant period, kind of

the first few months, to go on DonorNet,

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you know, you should have access to

DonorNet at your institution if you're

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a transplant ID provider, or if you're

taking care of transplant patients

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to be able to look in the chart, be

able to review the imaging, the labs,

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and all the findings from the donor.

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And you can see a lot of the social

history there to kind of think

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about what things the donor may

have put your recipient at risk for.

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Chelsea Gorsline: Yeah, agree.

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I think anytime we get a consult on

someone who's within the first few months

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of transplant and there's something

unusual going on, I think the first step

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should really be going back to the donor

and reviewing that in more detail to make

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sure nothing was missed because yeah,

there are some later onset donor derived

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infections that can still be pretty bad.

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And interestingly, you know, where I

practice in the Midwest, there was a few

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years ago a cluster of Ehrlichia donor

derived infection, which was pretty wicked

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and wild, um, and so I, I think being

aware of what region you're practicing

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in and what hyperspecific regional things

might be at risk is also important too.

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Rebecca Kumar: Yeah, and the other

thing to keep in mind is also for any of

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these donor calls, it's okay to talk to

other people, like within your division,

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or even outside of your division.

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You're always welcome to reach out to

myself, Courtney, or Chelsea, or Sara, if

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you have questions, because, you know, we

take these calls and we're happy to help.

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Courtney Harris: And there's a lot of

nuance, and so we have a group thread that

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we are always asking each other at other

institutions about our cases, like Rebecca

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and Chelsea and many of our other friends.

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Alan Koff has helped us with lots of

these donor calls, but it's nice to have

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a group and a big network to ask, which

makes me feel better about my decisions.

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So thank you guys.

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And I love you.

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Sara Dong: And I think that's a

really nice way for us to sort of

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start the conclusions, which is

reaching out to your colleagues,

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because these questions are not easy.

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And there's often a lot of nuance and

center specific things that it helps

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:

to bounce ideas off of someone else.

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But yeah, so maybe the last thing I'll

close with is just asking you guys,

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for those people who are interested

in transplant ID or maybe hearing more

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from the Early Career Network, is there

anything that you would direct people

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to, to get started or get involved?

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Courtney Harris: Yeah, so if you

want to check out more interesting

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content from our group, the Transplant

ID Early Career Network, you can

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find us active now on Blue Sky.

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And we also have several other

papers, as Sara mentioned earlier,

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that you may find of interest.

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Most of these are targeted at

trainees and young faculty to

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kind of figure out how to help you

navigate the field of transplant ID.

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So, this includes like securing

your first transplant ID job and

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helping negotiate for that position.

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Um, how to perform a transplant

ID pre transplant evaluation.

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Uh, how to write and collaborate on

a transplant ID protocol, which is a

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lot of what we do in our non clinical

time with the transplant teams.

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How to understand the nuances of

transplant ID training, whether this

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:

is tracks or formal years, there's

formal third year fellowships that

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you could do in transplant ID, or you

could do a track within your program.

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So there's a lot of differences

between those, um, how to become

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your best transplant ID steward.

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AKA being an MVP like Chelsea.

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And then also how to incorporate and be

involved in social media and transplant

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:

ID interacting with our group and others.

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We have a paper on that as well.

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So we really aim to create this content to

make the field of transplant ID accessible

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to all because while it's been around

a while, it's evolving, it's growing.

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And I think there are a lot of us who

are in our early careers who are so

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:

interested in helping develop the field.

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And I think reaching out to our group,

if you want to be involved, help host

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:

something with us or have an idea for

an event, we'd, we'd love to have more

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:

people involved and create great events

and content for you all going forward.

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Sara Dong: Thanks again to

Rebecca, Courtney, and Chelsea

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for joining Febrile today.

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Don't forget to check out

the website, febrilepodcast.

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com, where you'll find the consult

notes, which are written supplements to

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:

the episodes with links to references,

including the papers that we've mentioned.

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:

Our library of ID infographics

and a link to our merch store.

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Febrile is produced with support

from the Infectious Diseases

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:

Society of America, IDSA.

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Please reach out if you have any

suggestions for future shows or want

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:

to be more involved with Febrile.

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Thanks for listening, stay safe,

and I'll see you next time.

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