Successful Living Kidney Donation After COVID-19 Infection

The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic caused major disruptions in living donor kidney transplantation (LDKT). As of April 2020, 71.8% of LDKT programs in the United States suspended transplants^1,2 due to the elective nature of the surgery, concerns about donor and recipient exposure to the virus, and worries about further overwhelming healthcare resources.

We report a successful wife-to-husband LDKT after a resolved COVID-19 infection in the donor. The donor was in her late 50s and otherwise healthy except for primary hyperparathyroidism treated by parathyroidectomy. She worked in a healthcare facility and tested positive in mid-April 2020 for COVID-19 via polymerase chain reaction (PCR) on nasopharyngeal (NP) swab when she had odynophagia. The recipient is in his early sixties with diabetic dialysis-dependent kidney disease; he was asymptomatic and tested negative for the infection around the time of his wife’s diagnosis and again 2 months later. At the peak of the pandemic surge in Massachusetts, the pair’s evaluation was placed on hold until LDKT resumed at our institution after an almost 3-months halt. The donor had no residual symptoms, no kidney injury, proteinuria nor hematuria, normal chest imaging, and her repeat COVID-19 PCR NP testing was negative in June 2020. Serologic testing was not performed on either the donor or the recipient, as per the Infectious Diseases Society of America Guidelines on the Diagnosis of COVID-19.³ The pair was repeatedly screened for COVID-19 symptoms before surgery, and both tested negative with a COVID-19 PCR NP swab 48 h before the scheduled transplant, which occurred in early September 2020. Donor nephrectomy was uncomplicated, and the donor was discharged home 2 days after surgery. Iliac artery endarterectomy and patch angioplasty were necessary for the transplant, which was complicated by slow graft function without requiring dialysis, and antithymocyte globulin-associated cytokine release syndrome requiring brief respiratory support. The recipient was again negative by COVID-19 PCR NP swab on postoperative day 2 and was discharged home on postoperative day 10. Twenty-eight days after transplant, both donor and recipient were clinically well without respiratory symptoms and both with excellent kidney function.

Given the COVID-19 pandemic in the United States, it is only a matter of time before more candidates who have contracted and cleared the infection step forward to become a kidney donor. Concerns surrounding donation from candidates who have cleared the virus in the nasopharynx include risk of transmission (through blood or organ), impact of the infection on kidney function of both the donor and recipient, risk of respiratory decompensation in the donor with anesthesia, and healthcare resource utilization. There are also concerns around denying these candidates from donating with negative implications on donors’ quality of life,⁴ as well as on recipients’ survival as shown in a recent study suggesting survival advantage of LDKT under most scenarios pertinent to the COVID-19 pandemic.⁵ An increase in waitlist mortality has been seen across all solid organ transplants with a 43% increase in kidney waitlist deaths in April 2020 compared with previous monthly averages.² Given this, along with the fact that there is no known latent state of viral infection with SARS-CoV-2, we believe that select donor candidates who have cleared the virus without pulmonary, renal, or systemic complications, and no contraindications, should be accepted for donation. In this case, donation took place 2.5 mo after the first negative testing and 4.5 mo after the infection; however, one could argue that shorter intervals such as 4–6 wks after the first documented negative testing is acceptable and would be in line with available guidelines on operational aspects related to organ procurement in the COVID-19 era.⁶ A detailed explanation to the donor and the recipient candidates of the risks and benefits, the knowns and unknowns about COVID-19 as well as protocolized, multidisciplinary screening and testing before surgery are necessary to allow LDKT to proceed in the safest and most effective way possible.