Pretransplant screening to evaluate the risk of infection in hematopoietic cell transplant donors and candidates

CMV: cytomegalovirus; Ig: immunoglobulin; HBsAg: hepatitis B surface antigen; anti-HBsAg: antibodies to hepatitis B surface antigen; anti-HBc: antibodies to hepatitis B core antigen; RT-PCR: reverse transcriptase polymerase chain reaction; HIV: human immunodeficiency virus; VZV: varicella-zoster virus; HSV: herpes simplex virus; EBV: Epstein Barr virus; HTLV: human T lymphotrophic virus; VDRL: venereal disease research laboratory; TB: tuberculosis; SARS-CoV-2: severe acute respiratory syndrome coronavirus 2; VCA: viral capsid antigen; CBC: complete blood count; PCR: polymerase chain reaction.

* All HCT donors who are either anti-HBc positive or HBsAg positive and all HCT candidates who are anti-HBc positive but negative for HBsAg and anti-HBs should undergo viral load testing for hepatitis B virus. Additional recommendations for the evaluation and management of HCT candidates in the setting of positive serologic or viral load testing results from the donor or recipient can be found in the 2009 international guidelines^[1].

¶ In addition to serologic testing for hepatitis C, all HCT candidates should undergo a careful history and physical examination for risk factors, signs, and symptoms of hepatitis C, as well as serum alanine aminotransferase (ALT) testing. Hepatitis C viral load testing should be performed in all HCT donors as well as in HCT candidates at increased risk for hepatitis C infection, including those who have received a transfusion with blood not tested for hepatitis C (eg, before 1992 in developed countries), history of IV or inhaled drug use, tattoos, or unexplained elevation of serum ALT. Viral load testing should also be performed in HCT candidates with positive hepatitis C serologic testing. Additional recommendations for the evaluation and management of HCT candidates in the setting of positive serologic or viral load testing results from the donor or recipient can be found in the 2009 international guidelines^[1].

Δ Refer to UpToDate text for detail on HIV screening test selection.

◊ Approach to screening test selection varies among institutions.

§ Serum Aspergillus galactomannan antigen testing should be performed in HCT candidates who have a past history of invasive aspergillosis and in others who are high-risk for invasive aspergillosis.

¥ Screening for TB includes obtaining a history of prior active TB or exposures to individuals likely to have TB, as well as results of previous tuberculin skin tests or interferon-gamma release assays.

‡ The southeastern United States is an endemic region; testing should therefore be performed in individuals who have resided in or traveled to this region. If Strongyloides antibody testing is not available or if active disease with strongyloidiasis is suspected in a seronegative HCT candidate, three stool samples should be sent for ova and parasites.

† Reactivation of endemic mycoses following HCT is very rare, even in endemic regions.

** Donors or recipients who were born, received a blood transfusion, or ever lived for six months or longer in a region that is endemic for Chagas disease (eg, parts of South and Central America and Mexico) should undergo serologic testing for T. cruzi IgG. Individuals who have lived for less than six months in an endemic are but who had high-risk living conditions (eg, lived in dwellings with mud walls, unmilled logs and sticks, or a thatched roof), should also undergo serologic testing. Individuals whose mother was born in an endemic region or who has a suggestive history (eg, cardiomegaly and dysrhythmias) should be screened due to the risk of congenital transmission. Since there is no gold standard for serologic testing, screening should be performed with at least two serologic tests (enzyme immunoassay, indirect hemagglutination, indirect fluorescent antibody, or radioimmunoprecipitation assay).

¶¶ T. cruzi antibody testing of HCT donors is required in some states in the United States.

ΔΔ Donors who have traveled to a malaria-endemic area should defer donation for one year following their return. Former or current residents of endemic areas should defer donation for three years. If this is not feasible, the donor should be treated empirically for malaria prior to donation. If the donor is diagnosed with active malaria, collection of stem cells should be delayed if possible until treatment has been completed and negative confirmatory testing obtained. If this is not feasible, preemptive treatment of the HCT recipient is reasonable, although there is no evidence regarding the safety or efficacy of this approach.

◊◊ Potential HCT donors should be considered ineligible for HCT donation if they have been diagnosed with Zika virus infection over the past six months, resided in or traveled to an area with active mosquito-borne Zika virus transmission, or had sexual contact with a man who meets either of these criteria^[3]. Potential umbilical cord blood donors should be considered ineligible for donation if the birth mother has been diagnosed with Zika virus infection at any point during the pregnancy, resided in or traveled to an area with active Zika virus transmission at any point during the pregnancy, or had sexual contact at any point during the pregnancy with a man who meets either of these criteria.