Abstract and Introduction
Abstract
Emerging data support the safety of transplantation of extra-pulmonary organs from donors with SARS-CoV-2-detection. Our center offered kidney transplantation (KT) from deceased donors (DD) with SARS-CoV-2 with and without COVID-19 as a cause of death (CoV + COD and CoV+) to consenting candidates. No pre-emptive antiviral therapies were given. We retrospectively compared outcomes to contemporaneous DDKTs with negative SARS-CoV-2 testing (CoVneg). From February 1, 2021 to January 31, 2022, there were 220 adult KTs, including 115 (52%) from 35 CoV+ and 33 CoV + COD donors. Compared to CoVneg and CoV+, CoV + COD were more often DCD (100% vs. 40% and 46%, p < .01) with longer cold ischemia times (25.2 h vs. 22.9 h and 22.2 h, p = .02). At median follow-up of 5.7 months, recipients of CoV+, CoV + COD and CoVneg kidneys had similar rates of delayed graft function (10.3%, 21.8% and 21.9%, p = .16), rejection (5.1%, 0% and 8.5%, p = .07), graft failure (1.7%, 0% and 0%, p = .35), mortality (0.9%, 0% and 3.7%; p = .29), and COVID-19 diagnoses (13.6%, 7.1%, and 15.2%, p = .33). Though follow-up was shorter, CoV + COD was associated with lower but acceptable eGFR on multivariable analysis. KT from DDs at various stages of SARS-CoV-2 infection appears safe and successful. Extended follow-up is required to assess the impact of CoV + COD donors on longer term graft function.
Introduction
Since the start of the SARS-CoV-2 pandemic, death rates have increased significantly for all groups over age 15 and COVID-19 became the third leading cause of death.[1] While this is sobering, organ donation is a potential silver lining to increased death rates from any cause, particularly for younger individuals with unexpected deaths and preserved organ function. With the high prevalence of SARS-CoV-2 infection and the ongoing organ shortage, it was inevitable that the transplant community would have to directly address the use of organs from donors with SARS-CoV-2 RNA detection and from those dying of COVID-related causes with preserved organ function.
As was predicted by the pathophysiology of RNA respiratory viruses, transplantation of lungs from such donors would prove to be prohibitive. However, the use of extra-pulmonary organs from donors infected with SARS-CoV-2 has been controversial. Guidance from the Organ Procurement and Transplant Network Ad Hoc Disease Transmission Advisory Committee (OPTN-DTAC) recommends that programs balance the risk for SARS-CoV-2 transmission, the possible effects on allograft quality, and the risk to the procurement teams with the recipient's risk for mortality and other complications on the waitlist.[2] However, programs and organ procurement organizations (OPOs) must calculate these theoretical risks without additional guidance and may weigh the risk of transplantation too highly. Thus far, productive infection of extra-pulmonary organs remains unproven.[3–5] And while acute kidney injury is described for about a third of those hospitalized for COVID-19, it is often associated with other risk factors for renal injury and most often recovers.[6–8] Those with mild COVID-19 are even less likely to experience effects on kidney function.[7]
Due to caution at many levels, data for the use of organs from SARS-CoV-2 donors have grown slowly. Inadvertent transplantation from SARS-CoV-2 positive donors has led to devastating infection in lung recipients.[9,10] However, the use of extra-pulmonary organs from the same donors has resulted in no clinical signs of donor-derived SARS-CoV-2 and no reported ill- effects on allograft or patient outcomes.[9,11] Case reports, small case series and now recent summative OPTN data of liver, kidney and heart transplantation from donors with SARS-CoV-2 detection have been published with excellent recipient outcomes.[12–25] While the OPTN data is supportive of the safe use of organs from donors with SARS-CoV-2 detection, donor and recipient details that may illustrate the likelihood of active infection or infection-related complications are lacking.[25]
We previously reported our first 10 kidney transplants from SARS-CoV-2 positive donors many of whom may not have had active SARS-CoV-2 infection at the time of donation.[26] In the absence of alternative data to support a safety risk to our transplant candidates, we gradually loosened our restrictions for acceptance of kidneys from SARS-CoV-2 positive donors including those with evidence of active infection and those with death from COVID-related causes, organs that were often otherwise discarded during this time period. We aimed to report the safety of using these organs and the clinical outcomes compared to recipients of kidneys from CoVneg donors.
American Journal of Transplantation. 2022;22(12):2903-2911. © 2022 Blackwell Publishing
