Impact of COVID-19 in Solid Organ Transplant Recipients

Lara Danziger-Isakov; Emily A. Blumberg; Oriol Manuel; Martina Sester


American Journal of Transplantation. 2021;21(3):925-937. 

In This Article

Considerations in the Peri-transplant Period

SARS-CoV-2 infections in the early period after transplantation appears to have a higher morbidity and mortality as compared to infections in long-term transplant recipients, which may be directly related to the intense immunosuppressive drug regimens including induction therapies. Among 36 patients, 2 of 10 patients who died were early transplant recipients with T cell depleting agents received within the previous 5 weeks.[83] Similarly, two of five recent liver transplant patients died after nosocomial infection diagnosed 9 and 36 days after transplantation.[154] Finally, among three kidney and one liver transplant recipients who contracted SARS-CoV-2 infection from an asymptomatic surgeon between 7 and 10 days after transplantation, one kidney recipient died after rapid clinical deterioration.[155] Peri-transplant infection may also adversely affect graft outcome as suggested by a kidney transplant recipient with SARS-CoV-2 infection 24 days after transplantation who developed acute respiratory distress syndrome (ARDS) and AKI with induction of donor specific antibodies.[101] Based on the recognition of this higher risk, multiple transplant organizations have released recommendations regarding protecting newly transplanted patients from acquiring SARS-CoV-2.[41,45] Potential reasons for COVID-19 in the peri-transplant period include asymptomatic infection of the recipient at or around the time of transplantation, donor-derived infections, community acquired infections by family members or social contacts, or nosocomial transmission by health care workers and/or patients in health care facilities.[154–156] Screening of recipients and donors to exclude infection at the time of surgery seems mandatory as any type of surgery in a SARS-CoV-2 infected patient has been associated with significant postoperative pulmonary complications and high mortality. A European study involving 1128 patients with confirmed SARS-CoV-2 infection within 7 days before or 30 days after surgery were found to have a 30-day mortality of 23.8%, which increased to 38.0% among the 52.2% of patients with pulmonary complications.[157] Thus, apart from significant comorbidities among transplant recipients and intense immunosuppression in the early transplant period, transplant surgery itself might impact the outcome of recipients with asymptomatic or donor-derived infection. Although proven donor-derived infections have not yet been reported, this may be more likely to occur in lung transplant recipients due to a high burden of viable virus in the lung allograft. Given detection of viral RNA in other organs such as the gastrointestinal tract,[158,159] liver[160] or kidney,[161] transmission could also occur. The lack of donor-derived infections should not be considered as a low likelihood for transmission, but success of prevention policies including anamnesis to identify high-risk contacts and donor screening.[41,45,162] Continued vigilance and testing will not only protect potential recipients but also health care and transplant procurement teams and prevent viral transmission between institutions during procurement. Transplantation of infected candidates and utilization of organs from donors with COVID-19 are currently only recommended after resolution of clinical symptoms and negative PCR testing. Initial reports of transplant recipients with resolved SARS-CoV-2 infection have shown favorable outcome.[163] Case reports of inadvertent transplantation of asymptomatic SARS-CoV-2 positive donors without transmission to the recipient[164] may indicate a potential use of PCR positive donors for life-saving procedure, especially when more is known about the correlation between PCR positivity and infectivity.[108–110] After transplantation, strict adherence to careful infection prevention strategies and physical distancing are important preventive measures to prevent SARS-CoV-2 acquisition.[41,45,162] In SOT recipients who have contracted SARS-CoV-2, longer periods of PCR positivity[18–21] may require a longer duration of isolation and testing to reduce the risk for transmission.