1. © Northwestern University, NUTORC Discordant Serology and Nucleic Acid Testing Results for HIV, HBV and HCV in 2010 Nicole Theodoropoulos 1,3, Marek Nowicki 4, Claudia Chinchilla-Reyes 4, Carol Pancoska 5, Andres Jaramillo 6, Tom Mone 7, Rick Hasz 8, Martin D. Jendrisak 6, Daniela P Ladner 2,3, Michael G Ison 1-3 1 Divisions of Infectious Diseases and 2 Organ Transplantation, 3 Northwestern University Transplant Outcomes Research Collaborative, Northwestern University, 4 Mendez National Institute of Transplantation, 5 Labs Inc, 6 Gift of Hope Organ & Tissue Donor Network, 7 OneLegacy, 8 Gift of Life Donor Program American Transplant Congress – Boston, Massachusetts June 3, 2012

2. © Northwestern University, NUTORC 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.

3. © Northwestern University, NUTORC Background: Significant Organ Shortage Organ Transplants (2010)28,663 Current Waitlist Candidates114,425 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/

4. © Northwestern University, NUTORC 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 HIV o Prohibits the use of donors with + HIV test result o 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.asp Rogers et al. MMWR. 1994; 43(RR-8):1-17.

5. © Northwestern University, NUTORC Background: Nucleic Acid Testing (NAT) NAT can detect recent infection NAT increasingly used for donor screening 3,4 Window Periods by assay type 1,2 1 Kucirka L et al. Am J Transplant 2011;11(6):1188-200. 2 Kucirka L et al. Am J Transplant 2011;11(6):1176-87. 3 Orlowski et al. Am J Transplant. 2009; 9: 555. 4 Thedoropoulos N et al. Abstract LB17. ATC 2012. VirusSerologyNAT HIV22 days9 days HBV44 days22 days HCV66 days7 days YearHIV NATHBV NATHCV NAT 200878% of OPOs34% of OPOs78% of OPOs 201193% of OPOs75% of OPOs95% of OPOs

6. © Northwestern University, NUTORC Background: Nucleic Acid Testing (NAT) 1 Humar et al. Am J Transplant. 2010; 10: 889-899. Recent Consensus Conference reviewed issues related to use of NAT for donor screening 1 o Estimated the impact of false positive testing o Recommended NAT screening of increased risk donors and those with inadequate risk information only

7. © Northwestern University, NUTORC 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

8. © Northwestern University, NUTORC 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 Organizations o ~35% of the US Donor Pool All potential deceased organ donors were screened for HIV, HBV, and HCV according to current OPTN Policy o 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

9. © Northwestern University, NUTORC Methods: NAT Screening Lab ALab BLab C Year Initiated NAT2008 2004 Average NAT Volume 2 donors/week33 donors/week23 donors/week Assay SystemPCR TMA Donors ScreenedAll OPTN-defined increased risk donors All potential deceased organ donors* All potential deceased organ donors ConfirmationNone confirmedAt request of client As part of TMA assay Polymerase Chain Reaction (PCR) Assays o COBAS Ampliscreen HIV-1 Test Version 1.5, Roche Molecular Systems o COBAS Ampliscreen HCV Test Version 2.0, Roche Molecular Systems o COBAS HBV Ampliscreen, Roche Molecular systems* Transcription-Mediated Amplification (TMA) Assay o Procleix HIV-1/HCV Assay, Gen-Probe, Inc. *HBV NAT performed for all PDOD from 4/5 client OPOs

10. © Northwestern University, NUTORC Results: Serologic Screening 22 donors positive for both HBsAg and HBcAb. Lab Total ScreenedHIV EIA +HBs Ag +HBc Ab +HCV Ab + A387101911 B1,760715193150 C1,83022213488 Total3,977 10 (0.3%) 37 (0.9%) 346 (8.7%) 249 (6.3%)

11. © Northwestern University, NUTORC Results: NAT Screening LabHIV NATHBV NATHCV NAT A540 B1,7605011,760 C1,8100 Total Screened3,6245013,624 Total NAT Screening Volumes by Lab

12. © Northwestern University, NUTORC Results: HIV NAT Screening HIVSerology +Serology - NAT +8 (0.2%)10 (0.3%) NAT -1 (0.03%)3,605 (99.5%)

13. © Northwestern University, NUTORC Results: HIV NAT Non-Reproducible Results 10 HIV seronegative donors with + NAT o One PCR-based lab o 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 NAT o Built-in confirmatory step o All initial NAT + results were confirmed by discriminatory assay

14. © Northwestern University, NUTORC Results: HBV NAT Screening HBVSerology +Serology - NAT +8 (0.9%)*0 NAT -60 (12%) ° 433 (86.4%) *4 isolated +HBcAb; 4 +HBsAg and +HBcAb ° 56/60 were isolated +HBcAb

15. © Northwestern University, NUTORC Results: HCV NAT Screening HCVSerology +Serology - NAT +173 (4.8%)5 (0.1%) NAT -64 (1.8%) 3,382 (93.3%)

16. © Northwestern University, NUTORC Conclusions NAT was positive in 15 (0.4%) seronegative donors All HIV antibody negative/NAT positive results resulted from one PCR-based lab o 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 assay 1 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 utilization 2,3 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. 3 Taylor RM et al. Transplant Proc 2010;42:4479-87.

17. © Northwestern University, NUTORC 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 determine o The true incidence of seronegative, NAT positive donors o The effect of NAT screening on organ utilization o The false positive rates of NAT in the deceased organ donor population o 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

18. © Northwestern University, NUTORC Questions? Nicole Theodoropoulos, MD 312-695-5054 n-theodoropoulos@md.northwestern.edu nicoletheo15@gmail.com