/policies/,/policies/administrative/,/policies/administrative/uwhc/,/policies/administrative/uwhc/department-specific/,/policies/administrative/uwhc/department-specific/transplant/,/policies/administrative/uwhc/department-specific/transplant/transplant---solid-organ/,

/policies/administrative/uwhc/department-specific/transplant/transplant---solid-organ/310.policy

201707200

page

100

UWHC,

Policies,Administrative,UWHC,Department Specific,Transplant,Transplant - Solid Organ

Increased Risk Donor Organ Policy (3.10)

Increased Risk Donor Organ Policy (3.10) - Policies, Administrative, UWHC, Department Specific, Transplant, Transplant - Solid Organ

3.10



POLICY & PROCEDURE
Effective Date: November 2009
Revised Date: July 2017
Title: Increased Risk Donor Organ Policy Policy Number: 3.10

Page 1 of 4
I. PURPOSE

The purpose of this policy is to ensure patient safety and decrease the risk of transmission of
infectious diseases, notably: HIV, Hepatitis C, and Hepatitis B, to transplant recipients through donor
organs.

To ensure living donors are informed about disclosure of information that may quality them as
increased risk donors.

To ensure potential organ recipients are being provided with clear and understandable information to
allow them to make an informed decision about accepting increased risk donor organs prior to
transplantation.

II. POLICY

It is the policy of the UW Transplant program to adhere to the University of Wisconsin Hospital and
Clinics (UWHC) standards of patient care, as well as the standards determined by regulatory and
accrediting agencies, such as The Joint Commission, the Organ Procurement and Transplantation
Network (“OPTN”) and the United Network of Organ Sharing (“UNOS”) and the Centers for
Medicare and Medicaid Services (“CMS”), and any State and Federal laws.

III. FORMS

The following forms can be found on the “related tab” for this policy:
1. Living Donor Increased Risk Characteristics Questionnaire (301225-DT)
2. UW OTD Increased Risk for Disease Transmission – Reporting Form
3. Consent for Increased Risk Donors
4. Guidelines for Testing Recipients of Donor Organs Meeting CDC Criteria for Increased Risk
Classification
5. Increased Risk Donor Script
6. Coordination of Organ Transplants for CPTx








POLICY & PROCEDURE
Effective Date: November 2009
Revised Date: July 2017
Title: Increased Risk Donor Organ Policy Policy Number: 3.10

Page 2 of 4

IV. PROCEDURE

DECEASED DONORS
1. During family interviews, organ procurement staff identifies donors that fit guidelines for increased
risk behavior, as outlined by Public Health Service (PHS) 2013 Guidelines.
2. If potential donors meet any of the criteria (see attached Increased Risk for Disease Transmission
Reporting Form), the Organ and Tissue Donation ("OTD") medical director on call is notified and
makes a decision on whether these organs will be used for donation. If the decision is made to
proceed, the donor is considered "increased risk for transmitting HIV, Hepatitis B, and Hepatitis
C". This is communicated to the abdominal and cardiopulmonary transplant coordinators via the
OTD Coordinator.
3. ALL deceased donors are screened for infectious diseases according to OTD Policy 3.04. Results of
screening tests are entered into Donor Net by the OTD Coordinator.
4. Results are communicated via the OTD Coordinator to the abdominal and cardiopulmonary
transplant coordinators.
5. If a donor is identified as increased risk, the potential recipient of the organs will be notified by the
transplant coordinator calling him/her with the potential organ offer. The transplant coordinator
will read the increased risk donor script (see attached) to the patient. The patient must verbally
agree to accept the organ offer, and this verbal agreement is documented in the medical record by
the transplant coordinator.
6. Prior to surgery, the recipient surgeon or designated staff (i.e. transplant fellow or advanced
practice provider) will again verify consent to receipt of the increased risk donor organ and have the
patient complete and sign the consent form (see attached).
7. Recipients of donor organs meeting PHS Guidelines for Increased Risk will be tested for HIV,
Hepatitis C, and Hepatitis B before and after the transplant according to attached guidelines.
LIVING DONORS
1. Prior to donation, all living donors must complete the Living Donor Increased Risk Characteristics
Questionnaire (see attached). If donors choose not to complete the questionnaire, the donation
process will be stopped. Donors that are identified to be at increased risk for transmitting HIV,
Hepatitis B, or Hepatitis C per the PHS 2013 Guidelines will be identified as such. Donors sign the
form, acknowledging any concern for increased risk behavior will be shared with the intended
recipient. If the donors prefer this not to be shared with the recipient, they may withdraw from the
donation process. Donors will review and update this form the day prior to surgery. If a donor who



POLICY & PROCEDURE
Effective Date: November 2009
Revised Date: July 2017
Title: Increased Risk Donor Organ Policy Policy Number: 3.10

Page 3 of 4
had previously not been identified as Increased risk is identified as Increased risk on the day prior to
surgery, the surgery will be cancelled until appropriate testing can be performed.
2. The Living Donor Advocate will verify understanding of the consent form with all potential living
donor candidates.
3. The recipient will be notified of any potential increased risk behavior(s) uncovered in the Donor
Increased Risk Characteristics Questionnaire. They will be given the option as to whether to accept
the donor organ.
4. ALL potential donors will be screened for infectious diseases per the evaluation testing guidelines
(see Policies 4.33 and 5.33).
5. Donors that meet PHS guidelines for Increased risk will have repeat screening done approximately 2
weeks prior to the transplant surgery.
6. Recipients of donor organs meeting PHS guidelines for Increased risk classification will be tested for
HIV, Hepatitis C, Hepatitis B before and after the transplant according to the same guidelines used
for recipients of deceased donor high risk organs (see attached).
FOR ALL INCREASED-RISK DONOR CASES:
1. All consent form(s) will be scanned into the recipient patient's Health Link record.
2. Transplant data staff will be notified of donor increased risk status as well as names of recipients of
increased risk donor organs. This is noted in patient's electronic medical record ("Health Link").
3. Potential organ recipients are educated about risks of potential for disease transmission during the
evaluation process (See Policy 3.33 and 3.06).

V. REFERENCES

Organ Procurement Transplantation Network/United Network of Organ Sharing (OPTN/UNOS)
Policies located at www.optn.org or www.unos.org
Centers for Medicare & Medicaid Services (CMS) General Requirements for Transplant Centers, section
482.102.


VI. COORDINATION

University of Wisconsin Transplant Program






POLICY & PROCEDURE
Effective Date: November 2009
Revised Date: July 2017
Title: Increased Risk Donor Organ Policy Policy Number: 3.10

Page 4 of 4
VII. REVIEWED AND APPROVED BY

Kidney Transplant Manager
Liver Transplant Manager
Heart and Lung Transplant Manager
Operations Director


VIII. SIGNED BY


________________________________ _________________________________
Jill Ellefson, MBA Dixon Kaufman, M.D., PhD
Director, Organ Donation and Transplant Service Line Chair, UW Transplant Program