Should We Be Using COVID-Positive Donors for Organ Transplants?

Bruce Gelb, MD; Arthur L. Caplan, PhD

Disclosures

November 04, 2021

Arthur L. Caplan, PhD

Most of us worry about catching COVID. We worry about getting sick, even very sick (even though most of us won't, even if infected). People waiting for an organ transplant are more likely to get severely sick if they catch the virus from someone around them. But they have to worry about getting it another way as well: from their organ donor.

As the pandemic drags into its second winter, it looks like the threat from the virus won't be going away any time soon. About one third of patients admitted to the hospital with COVID have symptoms. The other two thirds of COVID-infected patients in the hospital are there for another reason and didn't even know they were infected until tested when they arrived.

Cadaver organ donors start out as patients in hospitals. When they die and specific criteria are met, a donor can save as many as eight lives and improve countless others with donated tissues.

After transplant, the risk of dying from COVID is much higher. Getting vaccinated helps, but it doesn't work as well in people who are immunosuppressed. Transplant patients need a third dose, and maybe even a fourth.

So, the stakes are higher. They also need vaccinated caregivers and to restrict their activities to settings where they can reasonably expect either low rates of COVID or very high rates of vaccination and masking.

Every time a donor organ is available, transplant surgeons have to evaluate the donor and their organs to decide whether they are suitable to transplant into an often desperate patient: Will this liver work? Is it the right size? My patient may soon be too sick to survive a surgery. If this organ is not used, what are the chances that another organ will become available that's better for my patient? Do I tell my patient that I am more conservative than other surgeons in deciding what organs are transplantable? Is the wait for their organ so long that they will go to a different transplant center?

A key risk is a transplant recipient catching a disease or infection from a transplanted organ. Donors have a ton of tests done, so there is very little that is missed, but it's not zero. If my patient does catch a virus from the donor, can it be treated? For hepatitis B and C, the answer is a resounding yes. For COVID, it's a no for lungs. For other organs it's an uncertain maybe.

Stratifying risk is inherent in the field of organ transplantation. But what is too much risk?

Early data suggest that organs can be donated by people who have recovered from COVID, even after just a few weeks. But what about a donor who still has the virus? COVID is a respiratory virus and lives in the lungs. It's spread by breathing and talking. So the lungs are out — definitely not a good idea to transplant them.

But what about the heart for a patient who is unlikely to survive waiting for another donor? Or a liver? That's probably less risky, but we don't know how much so yet. Dialysis can keep a patient going while waiting for a kidney, so the risk-benefit ratio isn't as good. A patient waiting for a face or hand transplant can certainly wait, but for how much longer if their donor match is like finding a needle in a haystack?

Each patient's acceptable amount of risk is different. Consent is key. How much ought we defer to their judgement on what is too risky? They need to know all risks, but what about scenarios like this, where we don't know exactly how risky this is until we have more data?

And transplant centers need protocols to manage COVID-positive organs and mandatory follow-up to get more data on outcomes. Guessing wrong can have a disastrous outcome for a patient who is immunosuppressed and battling COVID. But waiting for "something better" can mean death as well. Yet again, COVID has found another way to make our lives more stressful and the pandemic more miserable.

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