Early Success Transplanting Kidneys From Donors With New SARS-CoV-2 RNA Positivity

A Report of 10 Cases

Christine E. Koval; Emilio D. Poggio; Yi-Chia Lin; Hannah Kerr; Mohamed Eltemamy; Alvin Wee

Disclosures

American Journal of Transplantation. 2021;21(11):3743-3749. 

In This Article

Abstract and Introduction

Abstract

Transplantation of solid organs from donors with active SARS-CoV-2 infection has been advised against due to the possibility of disease transmission to the recipient. However, with the exception of lungs, conclusive data for productive infection of transplantable organs do not exist. While such data are awaited, the organ shortage continues to claim thousands of lives each year. In this setting, we put forth a strategy to transplant otherwise healthy extrapulmonary organs from SARS-CoV-2-infected donors. We transplanted 10 kidneys from five deceased donors with new detection of SARS-CoV-2 RNA during donor evaluation in early 2021. Kidney donor profile index ranged from 3% to 56%. All organs had been turned down by multiple other centers. Without clear signs or symptoms, the veracity of timing of SARS-CoV-2 infection could not be confirmed. With 8–16 weeks of follow-up, outcomes for all 10 patients and allografts have been excellent. All have been free of signs or symptoms of donor-derived SARS-CoV-2 infection. Our findings raise important questions about the nature of SARS-CoV-2 RNA detection in potential organ donors and suggest underutilization of exceptionally good extrapulmonary organs with low risk for disease transmission.

Introduction

Since March 2020, over 33 million SARS-CoV-2 infections with more than a half million deaths have occurred in the United States.[1] Despite uncertainties and pandemic-related disruptions, most transplant centers and organ procurement organizations have continued to provide these lifesaving therapies supported by infection prevention practices.[2,3] Nationwide, only a modest decrease in deceased donor transplantation occurred in 2020 compared to 2019.[4] However, the organ shortage persists with thousands of deaths on the transplant waitlist yearly, including over 4000 deaths while awaiting a kidney transplant in 2020.[5]

Those dying from severe COVID-19 are not considered for organ donation. Given the prevalence of infection, however, it was expected that those dying from other causes might also have active SARS-CoV-2 infection. By April 2020, SARS-CoV-2 screening was required for all potential organ donors to avoid the possibility of virus transmission to recipients through transplanted organs and to the medical teams during organ procurement. Those with detectable SARS-CoV-2 RNA have generally not been considered for donation unless there is evidence for successfully resolved infection.

While SARS-CoV-2 infection in the airway of potential donors is prohibitive of lung donation, transplantation of the extrapulmonary organs has been more controversial. An editorial by Kates, et al. published in July 2020 put forth a well-considered argument for use of such organs.[6] Early in the pandemic, most organ procurement organizations considered SARS-CoV-2-infected donors to be ineligible for organ donation. Recent guidance from the Organ Procurement Transplant Network Disease Transmission Advisory Committee suggests balancing the risk for SARS-CoV-2 transmission possible effects on allograft quality and risk to procurement teams with the recipient's risk for mortality and other complications on the waitlist.[7] Still, many centers do not consider allografts from such donors. Without convincing evidence to date for productive (or transmissible) infection of most transplantable extrapulmonary organs, we put forth a strategy at our center for transplanting such organs from selected donors with SARS-CoV-2 RNA detection on screening. While not restricted to kidneys, our strategy resulted in the following 10 kidney transplants from five deceased donors.

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