Organ Transplantation Using COVID-19-Positive Deceased Donors

Matthew J. Bock; Gabrielle R. Vaughn; Peter Chau; Jennifer A. Berumen; John J. Nigro; Elizabeth G. Ingulli

Disclosures

American Journal of Transplantation. 2022;22(9):2203-2216. 

In This Article

Abstract and Introduction

Abstract

The COVID-19 pandemic has influenced organ transplantation decision making. Opinions regarding the utilization of coronavirus disease-2019 (COVID-19) donors are mixed. We hypothesize that COVID-19 infection of deceased solid organ transplant donors does not affect recipient survival. All deceased solid organ transplant donors with COVID-19 testing results from March 15, 2020 to September 30, 2021 were identified in the OPTN database. Donors were matched to recipients and stratified by the COVID-19 test result. Outcomes were assessed between groups. COVID-19 test results were available for 17 694 donors; 150 were positive. A total of 269 organs were transplanted from these donors, including 187 kidneys, 57 livers, 18 hearts, 5 kidney-pancreases, and 2 lungs. The median time from COVID-19 testing to organ recovery was 4 days for positive and 3 days for negative donors. Of these, there were 8 graft failures (3.0%) and 5 deaths (1.9%). Survival of patients receiving grafts from COVID-19-positive donors is equivalent to those receiving grafts from COVID-19-negative donors (30-day patient survival = 99.2% COVID-19 positive; 98.6% COVID-19 negative). Solid organ transplantation using deceased donors with positive COVID-19 results does not negatively affect early patient survival, though little information regarding donor COVID-19 organ involvement is known. While transplantation is feasible, more information regarding COVID-19-positive donor selection is needed.

Introduction

The COVID-19 pandemic has influenced decision making related to solid organ transplantation in the United States since early 2020. The first case of coronavirus disease-2019 (COVID-19) infection in the United States (U.S.) occurred on Januar0y 21, 2020 in the state of Washington. This was followed by the declaration of a state of national emergency in the U.S. on March 13, 2020 (Figure 1). Over the following days, guidance was provided to transplant centers and organ procurement organizations (OPO) regarding the cessation of transplant activities in the U.S.[1–5] These initial recommendations led to a temporary decrease in overall waitlist and transplant activities, which returned to baseline within 2–3 months of the start of the pandemic.[5–7] Since this time, the use of organs from deceased donors with active or a history of COVID-19 infection has been in debate. Several reports recommend against the utilization of COVID-19-infected organ donors at the time of their publication owing to several reasons.[8–10] These factors include the risk of blood or allograft tissue transmission, damage to donor organs, lack of effective therapies, exposure of healthcare workers and recovery teams, disease transmission and propagation, and hospital resource utilization.

Figure 1.

Coronavirus disease-2019 (COVID-19) pandemic timeline of events. Rec'd, Recommended [Colour figure can be viewed at wileyonlinelibrary.com]

Despite these early recommendations, reports of organ transplantation using donors known to be actively infected with or recovered from COVID-19 infection began to emerge.[11–28] Initial reports came from donors who had previously been infected with COVID-19 but had subsequently recovered. Later cases included those with lower-risk donors and recipients who either had a personal history of COVID-19 infection in the past and/or had antibodies to COVID-19 present. Most of these studies report good early outcomes after transplantation, except for one lung transplant where the recipient and transplanting surgeon developed COVID-19 after transplantation.[14] The COVID-19 strain was confirmed to be the same for all three individuals. The recipient died on post-transplant day 61. Subsequently, the Organ Procurement and Transplant Network (OPTN) required all OPOs to perform lower respiratory tract testing for COVID-19 on all potential deceased lung transplant donors.[29] This has been the only reported fatality of a transplant recipient due to transmission of COVID-19 from a donor.

With this information, several authors have begun recommending the acceptance of low-risk donors with positive COVID-19 testing for recipients who would benefit from transplantation and have high expected waitlist mortality.[28,32] Risk factors identifying low-risk donors include a longer time since first positive COVID-19 test or symptoms, mild severity of disease, reassuring imaging findings, a cycle threshold >35, no recent (<14 days) exposures to individuals with COVID-19, and no history of acute respiratory distress syndrome or thrombosis. Additionally, the OPTN has provided updated recommendations regarding the acceptance of organs from deceased donors with positive testing or a history of COVID-19.[29] They state that the risk of transmission of the virus from donors with a history of COVID-19 greater than 21 days prior to organ recovery is low but recommend caution in accepting these organs. Donors with mild symptoms and 10–21 days since the start of illness or positive test have an unknown safety risk and acceptance of organs should depend on the medical urgency of the candidate, along with several other factors. No recommendations are given for donors diagnosed with active COVID-19 infection or within 10 days of organ recovery.

Despite these reports and recommendations, there have been few large series of COVID-19-positive donors with a very short duration of follow-up in all cases.[16,30,31] The OPTN database now contains COVID-19 test results for all potential donors, since the start of the pandemic, allowing for a larger scale evaluation of outcomes in this population. We hypothesize that the recent COVID-19 infection of deceased solid organ transplant donors does not negatively affect patient or graft survival.

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